CHIROPRACTIC INTAKE & HISTORY final

CHIROPRACTIC INTAKE & HISTORY
PATIENT INFORMATION
Who may we thank for referring you?
Patient Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Email*
example@example.com
Employer / School
Occupation
Spouseʼs Name

First NameLast Name
Spouseʼs Employer
Spouseʼs Occupation
Best Time/Way to Contact You
Days(check all that apply)

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Time(check all that apply)

Early morningMorningLunchAfternoonEveningLate evening
Way to Contact You(check all that apply)

EmailTelephoneText
Sex*

MaleFemaleOther
Date of Birth*

MonthDayYear
Date
Age Category*

Pediatric (0-15 years)Young Adult (16-25)Adult (26-64)Senior (65+)
Parent Information
Mother's Name
Mother's occupation
Mother's phone
Mother's email*
Father's name
Father's occupation
Father's phone
Father's email
Marital Status

MarriedWidowedSingleMinorSeparatedDivorcedPartnered
Are you currently pregnant?

YesNo
Iʼm due
Number of past pregnancies?
How many children do you have?
Childrenʼs health concerns?
IN CASE OF EMERGENCY, CONTACT
Name*

First NameLast Name
Relationship *
Contact Number*
Please enter a valid phone number.
INSURANCE
Insurance Company
Would you like us to check on your insurance?

NoYes
HOW CAN WE HELP YOU?
What brings you in today?

AutoChronic discomfortFallHome injuryJobSportsWellness Check UpOther
If you are already experiencing a symptom, what is it?
How bad is it? How intense are your symptoms? (circle one)

1

2

3

4

5

6

7

8

9

10

1 is NO SYMPTOMS, 10 is INTENSE SYMPTOMS
What does it feel like? (check all that apply)

NumbnessTinglingStiffnessDullAchingSharpCrampingNaggingShootingBurningThrobbingStabbingSwellingOther
If other selected, please explain
Is Your Condition:

Getting BetterGetting WorseNot Changing
What aggravates your condition?
Please circle areas where you have pain or other symptoms:
Please check all symptoms you have ever had, even if they do not seem related to your current problem.

HeadachesRinging in earsDiarrheaFeverCold feetDizzinessBuzzing in earsConstipationUrinary issuesHot flashesPins and needles in legsFatigueNeck stiffnessFaintingHeartburnPins and needles in armsSleeping ProblemsBack painLoss of balanceUlcersNumbness in legsCold sweatsMenstrual painNervousnessTensionNumbness in fingersMood swingsMenstrual irregularityUpset StomachLoss of smellDepressionLoss of tasteOther
If other selected, please list other symptoms
Now please check all symptoms that you CURRENTLY are experiencing

HeadachesRinging in earsDiarrheaFeverCold feetDizzinessBuzzing in earsConstipationUrinary issuesHot flashesPins and needles in legsFatigueNeck stiffnessFaintingHeartburnPins and needles in armsSleeping ProblemsBack painLoss of balanceUlcersNumbness in legsCold sweatsMenstrual painNervousnessTensionNumbness in fingersMood swingsMenstrual irregularityUpset StomachLoss of smellDepressionLoss of tasteOther
If other selected, please list other symptoms
Pediatric Section
Has your child been treated on an emergency basis?

yesno
If yes, please describe
MOTHER'S PREGNANCY EXPERIENCE
Did you experience any complications during your pregnancy? (Check all that apply)

Back/Other PainGestational DiabetesPre/EclampsiaStrep BNausea/VomitingOtherPre-TermFatigueSwelling
Please describe if you selected other
BIRTH HISTORY
Type of Birth (check all that apply)*

HospitalBirth CenterHomeNormal/VaginalBreechCaesareanScheduled/InducedEpidural
Did you experience problems during labor/delivery? If so, please describe.
AntibioticsCongenital AnomaliesFailure to ThriveJaundiceMeconiumRespiratory DistressExtended Hospitalization
Other, please describe
GROWTH & DEVELOPMENT
Infant Feeding:*

BreastBottleFormula
Number of hours of sleep:
Quality of Sleep:
At what age did your child:
Respond to Sound:
Crawl:
Hold Head Up:
Stand:
Sit Unsupported:
Walk Unsupported:
CHILDHOOD DISEASES, ILLNESSES, & VACCINATIONS
Has your child had any of the following (check all that apply)*

Chicken PoxMeaslesRubeolaMumpsRubellaPertussis/Whooping CoughNone
Has your child suffered from: (check all that apply)*

AllergiesAnemiaArm ProblemsAsthmaBack AchesBed WettingBehavioral ProblemsBroken BonesChronic Ear AchesColds/FluColicConvulsions/SeizuresDelayed SpeechDiabetesDigestive IssuesConstipationDiarrheaDizzinessFaintingHeadachesHeart TroubleHyperactivityHypertensionJuvenile Rheumatoid ArthritisJoint ProblemsLeg ProblemsNeck problemsNeuritisOrthopedic ProblemsParalysisPoor AppetiteRuptures/HerniasSinus TroubleTuberculosisWalking ProblemsNone
Other, please describe
Have you vaccinated your child?*

YesNoAs scheduledDelayed scheduled
HEALTH CONCERNS

Please list any other health concerns

	Please list any other health concerns according to severity	Rate of severity 1 = mild 10 = worst imaginable	When did this start?	If you had this condition before, when?	Did the problem begin with an injury?	% of the time pain is present
1
2
3
4

IMPACT OF YOUR SYMPTOMS

How is this symptom / condition interfering with your life? (check where appropriate)

	NO EFFECT	MILD EFFECT	MODERATE EFFECT	SEVERE EFFECT
Work / School
Exercise
Recreation
Sleep
Self Care
Energy
Relationships
Attitude
Patience
Productivity
Creativity
Other

If you selected other, please list activity
How committed are you to correcting this issue?

1 (NOT COMMITED)2345678910 (VERY COMMITED)
HEALTH & ILLNESS HISTORY
Please check the box beside any conditions that you have now or have ever had in the past. While they may seem unrelated to the purpose of the appointment, they can affect the overall diagnosis, care plan and the possibility of being accepted for care.

AIDS/HIVAlcoholismAnemiaAnxietyArteriosclerosisArthritisAsthmaAllergiesBack PainCardio IssuesCancerCirculation IssuesChemotherapyChildhood IllnessColitusCongenital Heart DefectDepressionDiabetesDifficulty BreathingDigestive IssuesDizzinessDrug AbuseElbow/Wrist/Hand IssuesEndocrine (Thyroid) IssuesFoot/Ankle IssuesGoutHeadachesHeart attackHeart DiseaseHeart SurgeryHepatitisHigh/low blood pressureHip IssuesImmune IssuesInsomniaKidney ProblemsLymphatic IssuesMigraineMultiple SclerosisNeck PainPacemakerPsychiatric ProblemsReproductive IssuesRheumatic FeverRinging in EarsScoliosisSevere menstrual issuesShinglesShoulder IssuesSinus ProblemsStrokeTMJ IssuesTuberculosisUrinary IssuesOsteoporosisOtherNoneOther

Have you had any surgeries, broken bones, auto accidents, or injuries? If so, when?

	SURGERY / BROKEN BONE / ACCIDENT / INJURY	Date
1
2
3

ALLERGIES, MEDICATIONS & SUPPLEMENTS

Please list all allergies you have and medications and supplements you currently take

	ALLERGIES (list)	MEDICATIONS (list)	SUPPLEMENTS (list)
1
2
3
4

STRESSORS
Because accumulation of stress affects our health and ability to heal, please list your top three stresses (you have ever had) in each category:
Physical stressors (accidents, falls, hours sitting per day, repetitive postures/motions, work related habits, etc.)
a.
b.
c.
How is your current physical stress?

ExcellentGoodFairPoorGetting betterGetting worse
Bio-chemical stress (smoke, unhealthy foods, missed meals, dehydration, drugs/alcohol, etc.)
a.
b.
c.
How is your current bio-chemical stress?

ExcellentGoodFairPoorGetting betterGetting worse
Mental/emotional stress (work, relationships, finances, self-esteem, etc.)
a.
b.
c.
How is your current mental/emotional stress?

ExcellentGoodFairPoorGetting betterGetting worse
On a scale of 1-10 (1 being very poor and 10 being excellent), please grade your present levels of stress:
At work:
At home:
At play:
On a scale of 1-10 (1 being very poor and 10 being excellent), please describe your:
Eating habits:
Exercise:
Sleep:
General health:
Water consumption:
Stress level:
PATIENT WELLNESS ASSESSMENT
What number do you think represents your health today?
In what direction is your health currently headed?
What are your health goals?
Immediate
Short Term
Long Term
Things I do currently to support my health include:

Drink plenty of waterPlay regularlyGet plenty of restHomeopathic remediesMaintain positive attitudeEat organically grown foodsVitamins, minerals or herbsMaintain the proper weightUse a cervical pillow
Please indicate which of these you do/have on a consistent basis:

Eat fast foodWork long hoursFeel overwhelmed/Exhausted/FatiguedExperience gas/Bloating/IndigestionExperience food sensitivities/AllergiesPeriods of constipation/Loose stools/IrregularitiesHistory of pinched nerve/Slipped or herniated disc/Joint degenerationPopping/Crackling/Stiffness in your jointsFamily diagnosed with Osteoporosis/Thin brittle bonesMuscle cramps (sports or menstrual)Anxiety/NervousnessWeak or thin/Hair/Nails/SkinTooth decayFamily history of heart diseaseLow energy/Loss of vitalityFamily history of colds/Flus/Infections/Poor immune systemPoor gum health/GingivitisCravings for sugary foodsStruggle with weight lossLack of protein in dietHigh cholesterolStruggle with eating healthy throughout the dayCurrently taking vitamin supplements
This office conforms to the current HIPPA information privacy guidelines. You may request a copy of our HIPPA policy at the front desk at any time. Please check to indicate you have been made aware of its availability.*

I consent to a professional and complete chiropractic examination and to any examination that the doctor deems necessary.I understand that any fee for service rendered is due at the time of service and cannot be deferred to a later date.
Print Patient Name:*

First NameLast Name
Parent or Guardian Name

First NameLast Name
Date:*

MonthDayYear
Date
Signature:*

Clear
CANCELLATION POLICY
Our goal is to provide quality health care to all our patients in a timely manner. When you book your appointment, you are holding a space on our calendar that is no longer available to other patients. In order to be respectful of other fellow patients, please call our office as soon as you know you will not be able to make your appointment. If cancellation is necessary, we require that you call at least 24 hours in advance. Appointments are in high demand, and your advanced notice will allow another patient access to that appointment time.

Our Policy:
- We require a payment of $47 to hold your appointment.
- Any cancellation made less that 24 hours in advance will result in this fee being non-refundable
- In the event of a true, unavoidable emergency, all or part of your cancellation fee may be applied to future services.
Agreement*

I agree to this cancellation policy
Should be Empty:

CHIROPRACTIC INTAKE & HISTORY

Parent Information

Pediatric Section