• Confidential Patient Case History

  • Thank you for allowing us to address your health needs. The information on this questionnaire will help us determine if chiropractic care can help you. If we do not sincerely believe your condition will respond satisfactorily, we will not accept your case.

  • Which clinic are you inquiring about?*

  • ABOUT YOU:

    Patient Information
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Text reminders:
  • Date of Birth
     - -
  • Gender

  • SPOUSE CONTACT INFORMATION:

  • Marital Status:
  • Date of Birth
     - -
  • Format: (000) 000-0000.

  • ADDITIONAL EMERGENCY CONTACT INFORMATION

    Other than spouse
  • Format: (000) 000-0000.

  • ELECTRONIC HEALTH RECORDS (EHR) INTAKE:

  • Preferred method of communication for patient reminders:
  • Smoking Status:
  • Race:
  • Ethnicity:

  • ABOUT YOUR CONDITION:

  • If this is an injury, check one of the following:

  • *Please inform the front desk, as additional paperwork and appointment time may be required.

  • Date symptoms appeared
     - -
  • Have you had similar symptoms in the past?

  • Doctors you have seen for this condition:

  • Format: (000) 000-0000.
  • Have x-rays been taken for the area of concern?

  • FAMILY HEALTH HISTORY:

  • Many health problems are a result of hereditary conditions.Therefore, information about your family will give us a better understanding of your total health picture.

  • GENERAL HEALTH HABITS:

  • Are you currently taking any medications?
  • Do you have any medication allergies?

  • How many hours do you:

  • Do you eat a well-balanced diet?
  • Females only: Are you pregnant?
  • Females only: Nursing?

  • YOUR HEALTH HISTORY:

  • Do you have any difficulty with any of the following: Check
  • Rows

  • I understand the above information and guarantee this form was completed correctly to the best of my knowledge.  I also understand it is my responsibility to inform this office of any changes in my health or insurance status. 

  • Date
     - -
  • Should be Empty: