youkerchiro.com - Health Questionnaire

Patient First & Last Name::

First NameLast Name

Date:

Date

11. Have you had similar symptoms in the past?

YesNo

If yes, describe:

12. Describe any pertinent prior trauma/accidents:

13. Have you received previous chiropractic care?

YesNo

If yes, doctor’s name and date of last treatment:

14. During the past 4 weeks:

a. How much have your symptoms interfered with your normal work (including work outside the home, and housework)?

b. How much of the time has your condition interfered with your social activities (like visiting friends/relatives, sports, etc.)?

15. Family Medical Doctor:

Phone:

Please enter a valid phone number.Format: (000) 000-0000.

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of last physical exam:

Date

May we contact your M.D. if needed (for reports, pertinent information, updating your care, etc.)?

YesNo

16. WOMEN ONLY:

Are you pregnant, or is there any possibility you may be pregnant?

YesNo

If yes, what is your delivery date?

Date

Do you have breast implants?

YesNo

The statements made on this form are accurate to the best of my knowledge, and I agree to allow YOUKER CHIROPRACTIC to examine me for further evaluation.

Signature: (Patient, Parent, Legal Guardian)

Date

Doctor's Notes - Office Use Only

CONFIDENTIAL HEALTH QUESTIONNAIRE

CONFIDENTIAL HEALTH QUESTIONNAIRE