Re-Activation Updated Health Record
East West Chiropractic
Today's Date
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/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name:
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First Name
Last Name
Guardian's Name (if minor)
Address
*
Address
Street Address Line 2
City
State
Zip
Birth Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
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Ethnicity
Gender
*
Male
Female
Cell Phone
*
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
E mail
*
example@example.com
Occupation
*
Employer
Primary Care Physician
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Primary Care Physician City
*
Marital Status
*
Married
Single
Widowed
Divorced
Emergency Contact
*
Relationship to You
*
Emergency Contact Phone #
*
Format: (000) 000-0000.
Are you insured?
*
Yes
No
Insurance Company
Insurance ID#
Insurance Group #
Cardholder's Name
Cardholder's Date of Birth
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Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Your Social Security #
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Reason for This Visit
Is this visit the result of a work or auto injury?
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Yes
No
Describe the purpose of this visit
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How did this condition begin?
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When did this condition begin?
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Is the condition:
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Getting worse
Not changing
Getting better
Is the condition:
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Constant
Comes and Goes
What makes it better? (rest, ice, heat, positioning, etc.)
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What makes it worse?
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Sitting
Standing
Walking
Changing positions
Twisting
Lifting
Laying/sleeping
Reaching
Bending
Going up/downstairs
Deep breaths
Cough/Sneeze/Bowel movements
Other
Does the pain:
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Stay in one spot
Travel to other areas
If the pain travels, where to?
Please describe the pain. Select all that apply.
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Ache
Sharp
Shooting
Burning
Pins and needles
Numbness
Other
Is your pain worse in the
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AM
PM
No difference
Please rate the severity of your pain at its BEST (10 being the worst):
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1
2
3
4
5
6
7
8
9
10
None
Please rate the severity of your pain at its WORST (10 being the worst):
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1
2
3
4
5
6
7
8
9
10
Please rate the AVERAGE or most typical severity of your pain (10 being the worst):
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1
2
3
4
5
6
7
8
9
10
Has this condition occurred before? If yes, how often?
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Have you ever seen any other doctors/massage/acupuncture, etc. for this condition?
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Yes
No
If yes, who did you see?
What other types of treatment have you had for this condition?
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Did the other types of treatment help?
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Yes
No
Temporary relief
Any other prior injuries: (i.e. car accidents, falls, etc. or none)
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Any other odd/unusual changes in the last few months: (i.e. unexplained weight loss/gain, fatigue, changes in bowel/bladder function, ect or NA.)
*
Please mark the location of your pain on the drawing
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Health History
Current Medications and Supplements: *please check all that apply*
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High Blood Pressure
High Cholesterol
Anti-anxiety
OTC NSAIDs (Tylenol, Motrin, ect.)
Multivitamin
Vitamin C
Prescription Pain Medication
Thyroid Medication
Antibiotics
Probiotic
Vitamin D
Insulin
Blood Thinners
Allergy
Steroids/Anti-inflammatory
Omegas
Calcium
Muscle Relaxers
Anti-depressant
Medical Marijuana
Fiber
Tumeric
Other
Please list any major health changes since your last visit:
*
Please list any surgeries with dates since your last visit:
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Any other changes since your last visit the office needs to be aware of?
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Smoking:
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Former Smoker
Never Smoked
Smoking packs/day:
Number of alcoholic beverages per week:
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Number of cups of coffee/caffeine per day:
*
Number of ounces of water you drink per day:
*
Do you exercise? If yes, what type and how often:
*
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For Women Only:
Start Date of Last Menstrual Cycle:
Are you taking birth control? (yes or no)
Are you pregnant? (yes or no)
If yes, when are you due?
Submit
Should be Empty: