Advantage Health Center
Chiropractic Intake and History
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Sex
Male
Female
Relationship Status
Married
Divorced
Separated
Single
Minor
Employer / School
Occupation
IN CASE OF EMERGENCY CONTACT
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Who may we thank for referring you?
HOW CAN WE HELP YOU?
What brings you in today?
How bad is it on a scale of 1-10 (10 being the worst)?
Best
1
2
3
4
5
6
7
8
9
Worst
10
1 is Best, 10 is Worst
What does it feel like? (check all that apply)
Numbness
Tingling
Stiffness
Dull
Aching
Cramping
Nagging
Sharp
Shooting
Burning
Throbbing
Stabbing
Swelling
IMPACT OF YOUR SYMPTOMS
How is this symptom/condition interfering with your life? (check where appropriate)
Work
No Effect
1
2
3
4
Severe Effect
5
1 is No Effect, 5 is Severe Effect
Exercise
No Effect
1
2
3
4
Severe Effect
5
1 is No Effect, 5 is Severe Effect
Recreation
No Effect
1
2
3
4
Severe Effect
5
1 is No Effect, 5 is Severe Effect
Relationships
No Effect
1
2
3
4
Severe Effect
5
1 is No Effect, 5 is Severe Effect
Sleep
No Effect
1
2
3
4
Severe Effect
5
1 is No Effect, 5 is Severe Effect
Self Care
No Effect
1
2
3
4
Severe Effect
5
1 is No Effect, 5 is Severe Effect
Energy
No Effect
1
2
3
4
Severe Effect
5
1 is No Effect, 5 is Severe Effect
Attitude
No Effect
1
2
3
4
Severe Effect
5
1 is No Effect, 5 is Severe Effect
Patience
No Effect
1
2
3
4
Severe Effect
5
1 is No Effect, 5 is Severe Effect
Productivity
No Effect
1
2
3
4
Severe Effect
5
1 is No Effect, 5 is Severe Effect
Creativity
No Effect
1
2
3
4
Severe Effect
5
1 is No Effect, 5 is Severe Effect
How committed are you to correcting this issue?
Not Committed
1
2
3
4
5
6
7
8
9
Very Committed
10
1 is Not Committed, 10 is Very Committed
PATIENT WELLNESS ASSESSMENT
What number do you think represents your health today?
Disease
1
2
3
4
5
6
7
8
9
Optimal Health
10
1 is Disease, 10 is Optimal Health
In what direction is your health currently headed?
Towards Health
Towards Disease
HEALTH GOALS
IMPORTANT
IMMEDIATE
WHAT DO YOU WANT RIGHT NOW?
SHORT TERM
WHAT DO YOU WANT TO GET BACK TO?
LONG TERM
WHAT DO YOU WANT TO BE ABLE TO DO?
HEALTH & ILLNESS HISTORY
Please check the box beside any condition that you have or have had.
AIDS/HIV
Alcoholism
Arteriosclerosis
Arthritis
Asthma/Allergies
Back pain
Cardiovascular Issues
Cancer
Circulation Issues
Childhood illness
Depression
Diabetes
Fibromyalgia
Chronic Fatigue
Elbow/wrist issues
Foot/Ankle issues
Gout
Hashimotos
Hypothyroidism
Hyperthyroidism
Headaches
Hip issues
Immune Issues
Lymphatic Issues
Multiple Sclerosis
Neck Pain
Reproductive Issues
PMS
Emotional imbalance
Ringing in ears
Scoliosis
Shoulder issues
Stroke
TMJ issues
Urinary Issues
Osteoperosis
Irritable Bowel Syndrome
Chron's Disease
Ulcerative Colitis
Eczema
GUT HEALTH QUESTIONNAIRE
In healthcare today, leaky gut aka intestinal permeability, isn't typically diagnosed. However that doesn't mean it's not affecting your health. Many health issues related to gut health go undiagnosed, misdiagnosed, or are ignored by traditional medicine. Please complete this section to help our doctors determine how we can help you get better results, faster!
Circle the number that most closely fits you:
Constipation and/or diarrhea
None
0
1
2
Severe
3
0 is None, 3 is Severe
Abdominal pain or bloating
None
0
1
2
Severe
3
0 is None, 3 is Severe
Mucous or blood in stool
None
0
1
2
Severe
3
0 is None, 3 is Severe
Joint pain or swelling, arthritis
None
0
1
2
Severe
3
0 is None, 3 is Severe
Chronic or frequent fatigue or tiredness
None
0
1
2
Severe
3
0 is None, 3 is Severe
Food allergies, sensitivities or intolerance
None
0
1
2
Severe
3
0 is None, 3 is Severe
Sinus or nasal congestion
None
0
1
2
Severe
3
0 is None, 3 is Severe
Chronic or frequent inflammations
None
0
1
2
Severe
3
0 is None, 3 is Severe
Eczema, skin rashes or hives
None
0
1
2
Severe
3
0 is None, 3 is Severe
Asthma, Hay fever, or airborne allergies
None
0
1
2
Severe
3
0 is None, 3 is Severe
Confusion, poor memory or mood swings
None
0
1
2
Severe
3
0 is None, 3 is Severe
Use of NSAIDS (Aspirin, Tylenol, Motrin)
None
0
1
2
Severe
3
0 is None, 3 is Severe
History of antibiotic use
None
0
1
2
Severe
3
0 is None, 3 is Severe
Alcohol consumption makes you feel sick
None
0
1
2
Severe
3
0 is None, 3 is Severe
Gluten sensitivity or Celiac's disease
None
0
1
2
Severe
3
0 is None, 3 is Severe
Nausea
None
0
1
2
Severe
3
0 is None, 3 is Severe
Weight issues
None
0
1
2
Severe
3
0 is None, 3 is Severe
Submit
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