CONFIDENTIAL HEALTH INFORMATION

Personal History.

11. Personal Illnesses

Check the illnesses you have Had in the past or Have now.

	Had	Have
AIDS
Alcoholism
Allergies
Arteriosclerosis
Cancer
Chicken pox
Diabetes
Epilepsy
Glaucoma
Goiter
Gout
Heart disease
Hepatitis
HIV Positive
Malaria
Measles
Multiple Sclerosis
Mumps
Polio
Rheumatic fever
Scarlet fever
Sexually transmitted disease
Stroke
Tuberculosis
Typhoid fever
Ulcer
Other

If Other:

12. Operations

Surgical interventions, which may or may not have included hospitalization.

	Check
Appendix removal
Bypass surgery
Cancer
Cosmetic surgery
Elective surgery:
Eye surgery
Hysterectomy
Pacemaker
Spine
Tonsillectomy
Vasectomy
Other

If Elective Surgery

If Spine Surgery

If Other Surgery

13. Treatments

Check the ones you’ve received in the Past or are receiving Currently.

	Past	Currently
Acupuncture
Antibiotics
Birth control pills
Blood transfusions
Chemotherapy
Chiropractic care
Dialysis
Herbs
Homeopathy
Hormone replacement
Inhaler
Massage therapy
Physical therapy
Medications

(Please list below all prescription, over-the-counter, natural supplements, enzymes, vitamins and minerals):

14. Allergies

Are you allergic to any medications?

YesNo

If Yes please list:

15. Injuries

Have you ever...

16. Family History

	Age (If living)	State of health-Good	State of health-Poor	Illnesses	Age at death	Cause of death-Natural	Cause of death-Illness
Mother
Father
Sister 1
Sister 2
Brother 1
Brother 2

17. Are there any other hereditary health issues that you know about?

18. Social History

	Daily	Weekly	How much?
Alcohol use
Coffee use
Tobacco use
Exercising
Pain relievers
Soft drinks
Water intake

Prayer or meditation?

YesNo

Job pressure/stress?

YesNo

Financial peace?

YesNo

Vaccinated?

YesNo

Mercury fillings?

YesNo

Recreational drugs?

YesNo

Hobbies

19. Activities of Daily Living

How does this condition currently interfere with your life and ability to function?

	No Effect	Mild Effect	Moderate Effect	Severe Effect
Sitting
Rising out of chair
Standing
Walking
Lying down
Bending over
Climbing stairs
Using a computer
Getting in/out of car
Driving a car
Looking over shoulder
Caring for family
Grocery shopping
Household chores
Lifting objects
Reaching overhead
Showering or bathing
Dressing myself
Love life
Getting to sleep
Staying asleep
Concentrating
Exercising
Yard work

20. What is the major stressor in your life?

21. How much sleep do you average per night?

Hours

22. What is the type and approximate age of your mattress and pillow?

23. What is your preferred sleeping position?

24. Describe your typical eating habits:

Skip breakfastTwo meals a dayThree meals a daySnacking between meals

25. What would be the most significant thing that you could do to improve your health?

26. In addition to the main reason for your visit today, what additional health goals do you have?

27. Do you wear orthodics?

YesNo

28. Do you wear a heel lift?

YesNo

29. Previous chiropractic care?

YesNo

When?

Acknowledgements

To set clear expectations, improve communications and help you get the best results in the shortest amount of time, please read each statement and initial your agreement. Click on boxes under Initial columns to type in your initials.

	Initial
I instruct the chiropractor to deliver the care that, in his or her professional judgement, can best help me in the restoration of my health. I also understand that the chiropractic care offered in this practice is based on the best available evidence and designed to reduce or correct vertebral subluxation. Chiropractic is a separate and distinct healing art from medicine and does not proclaim to cure any named disease or entity.
I may request a copy of the Privacy Policy and understand it describes how my personal health information is protected and released on my behalf for seeking reimbursement from any involved third parties.
I realize that an X-ray examination may be hazardous to an unborn child and I certify that to the best of my knowledge I am not pregnant.
I grant permission to be called to confirm or reschedule an appointment and to be sent occasional cards, letters, emails or health information to me as an extension of my care in this office.
I acknowledge that any insurance I may have is an agreement between the carrier and me and that I am responsible for the payment of any covered or non-covered services I receive.
To the best of my ability, the information I have supplied is complete and truthful. I have not misrepresented the presence, severity or cause of my health concern

Patient (or Guardian’s) signature*

Date

	Had	Have
Osteoporosis
Arthritis
Scoliosis
Neck pain
Back problems
Hip disorders
Knee injuries
Foot/ankle pain
Shoulder problems
Elbow/wrist pain
TMJ issues
Poor posture

	Had	Have
Anxiety
Depression
Headache
Dizziness
Pins and needles
Numbness

	Had	Have
High blood pressure
Low blood pressure
High cholesterol
Poor circulation
Angina
Excessive bruising

	Had	Have
Asthma
Apnea
Emphysema
Hay fever
Shortness of breath
Pneumonia

	Had	Have
Anorexia/bulimia
Ulcer
Food sensitivities
Heartburn
Constipation
Diarrhea

CONFIDENTIAL HEALTH INFORMATION

Please describe your Primary Complaint in the space below. Use the Secondary and Additional Complaint boxes if they apply.

Past Personal, Family and Social History

	Had	Have
Blurred vision
Ringing in ears
Hearing loss
Chronic ear infection
Loss of smell
Loss of taste

	Had	Have
Thyroid issues
Immune disorders
Hypoglycemia
Frequent infection
Swollen glands
Low energy

	Had	Have
Kidney stones
Infertility
Bedwetting
Prostate issues
Erectile dysfunction
PMS symptoms

	Had	Have
Fainting
Low libido
Poor appetite
Fatigue
Sudden weight loss
Sudden weight gain
Weakness

	Had	Have
Skin cancer
Psoriasis
Eczema
Acne
Hair loss
Rash