Adult Patient Questionnaire

Adult Patient Questionnaire
Name *

First Name Last Name
Please enter your date of birth *

Month Day Year
Date
Phone Number *

Area Code Phone Number
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Please enter your social security number
Please note: We are unable to set up any payment plan arrangement without a valid social security number. If you choose not to provide your social security number, payment will be expected in full at time of service.
What is your occupation?
Who is your employer?
Who referred you to our office today? *

a friend/family member my doctor Google Facebook Eventbrite Meetup
If referred by a friend, family or doctor, please provide their name so that we may thank them:
Have you ever seen a Chiropractor before? If so, what was the reason for stopping?
EMERGENCY CONTACT
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Email
example@example.com
Relationship to you *
CURRENT HEALTH INFORMATION

Please use the following fields to describe what brings you into our office today.
I am seeking pain relief I am not currently experiencing pain, I am seeking to improve overall function

Rate your current health status

	1	2	3	4	5	6	7	8	9	10

1 is Terrible, 10 is Fantastic

Please list your health concerns.
Please check all the symptoms that you are currently experiencing: *

Dizziness Difficulty Sleeping Food Sensitivities/Intolerances Loss of Libido Nausea Poor Concentration Abdominal Pain Muscle Cramping Indigestion Constipation Poor circulation Anxiety Night Sweats Headaches Changes in Bowel/Bladder Function Pain Swelling Narcolepsy Fatigue Allergies High Blood Pressure Difficulty Breathing Weakness Vertigo Sinus Trouble Menstrual Problems Diarrhea Gas Bloating Depression Stress Migraines Pain at Night Unexplained Weight Loss/Gain Stiffness Abnormal Lumps
Are you currently or do you regularly experience any of the following:

Neck pain Upper back pain Mid back pain Lower back pain

Please rate your pain *

	1	2	3	4	5	6	7	8	9	10

1 is No pain, 10 is Extreme pain

The quality of my pain listed above is characterized as

burning stabbing dull/ache stiff pins and needles tingling
The pain is

constant comes and goes
Does this pain radiate/shoot to other areas of your body?

Yes No
If you answered yes the the last question (your pain radiates), please select which areas are affected:

shoulder / arm / hands / fingers buttocks / leg ankle / foot left right both left and right
Please select all the things that make your pain better:

ice heat rest movement / position change sitting standing stretching Rx medication OTC medication
Please select all of the things that make your pain worse

sitting standing movement / position change walking lying down sleeping heat

Please indicate how your condition impacts these activities:

Painful

Some pain

Not affected

Bending

Lifting

Stairs

Sitting

Standing

Walking

Exercising

Housework

Kneeling

Please select any other providers who have treated this condition:

primary care physician orthopedic doctor massage therapist physical therapist another chiropractor
Is your pain a result of any of the following?

motor vehicle accident personal injury worker's compensation none of the above
What are your current health goals? Please write at least your top 3. *
1.
2.
3.
Please enter your height:
Please enter your approximate weight (lbs):
LIFESTYLE HABITS

Tell us a little about yourself and your lifestyle.
How many hours per week do you work?
Is your work physically strenuous?

Yes No
Is your work emotionally stressful?

Yes No
Are you in direct contact with any man-made chemicals at work?
Cleaning agents, petroleum products, etc. Please list them.
Do you experience any stress at home? If yes, please describe.
How many hours per day do you sit?

Less than 4 hours 4-8 hours More than 8 hours
How many hours per day do you stand?

Less than 4 hours 4-8 hours More than 8 hours
How long are you in front of a screen daily?

Less than 2 hours 2-4 hours 4-6 hours 6-8 hours More than 8 hours
How much water do you drink daily?

Less than 80oz Approx. 80oz More than 80oz
Please list any prescription medications you are currently taking or write none. *
Please list any supplements you are currently taking or write none. *
Do you use tobacco products OR vape?

Yes No Occasionally
Which statement best describes your exercise habits?

I exercise regularly and frequently (3+ times per week on a regular basis) I exercise regularly but not frequently (1-2 times per week on regular basis) I exercise every once in a while I don't exercise
How often do you consume alcoholic drinks?

rarely / never 1-3 drinks per week 3-5 drinks per week over 6 drinks per week
Which best describes your eating habits?

I eat fast food regularly (3+ times per week) I eat out sometimes and make healthy choices I eat clean (organic, whole foods most of the time)
HEALTH HISTORY

Please indicate any past or present conditions listed below. Check all that apply.
General: *

recent unintentional weight loss fever extreme fatigue none in this category
Musculoskeletal: *

broken bones previous surgery (please explain in next section)
Neurological: *

numbness or tingling loss of feeling dizziness or lightheaded frequent or recurrent headaches head injury / concussion none in this category
Gastrointestinal: *

loss of appetite bloody stool constipation diarrhea nausea or vomiting regular abdominal pain / bloating none in this category
Cardiovascular/Heart: *

chest pain rapid or heartbeat changes blood pressure regulation problems high cholesterol swelling of ankles or feet none in this category
Respiratory: *

difficulty breathing shortness of breath persistent cough asthma coughing blood none in this category
Eyes/Vision *

blurred/double vision eye disease or injury wear glasses/contacts none in this category
Genitourinary *

kidney stones burning/painful urination frequent urination urinary leakage/bed wetting blood in urine none in this category
Endocrine, hematologic, lymphatic *

thyroid problems diabetes cold hands/feet autoimmune/immune system disordr none in this category
Skin and breasts *

rash/itching non-healing sores breast pain breast lump none in this category
For women only: Are you pregnant?

Yes No It's possible
If yes, what is your estimated due date?

Month Day Year
Date
Do you have an immediate family history of any of the following? *

cancer heart disease stroke none of the above
Have you been treated for any health conditions in the last year?

Yes No
If yes, please explain:
Have you ever been diagnosed with any chronic illnesses or conditions?

Yes No
If yes, please explain:
Have you ever been hospitalized, had any surgeries, or major accidents?

Yes No
If yes, please explain listing year and what happened:
Have you had any x-rays or other imaging within the past 3 months?

Yes No
If yes, please explain which x-rays and why they were taken:
How many times per year do you get sick (cold, flu, sinus infection, etc.)?

CONSENTS
Accuracy of Information *

I certify that the above information is correct to my knowledge.
By checking this box, I agree that I have read and understand the information below. *

During your examination the doctor may decide it is medically necessary to include digital x-ray imaging of one or more areas of your spine or extremity. Women who think they may be pregnant will not be imaged. Please let your doctor know if there is a chance you may be pregnant. As with any healthcare procedure, there are certain complications which may arise during a chiropractic adjustment/massage therapy/ acupuncture/cold laser. These complications include but are not limited to: muscle strain, tenderness, fractures, soft tissue injuries, cervical radiculitis and costovertebral strains. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to complications including stroke. Some patients will feel some stiffness and soreness following the first few days of treatment. We use comprehensive examinations to screen for contraindications to care; however, if you have a condition that would otherwise not come to our attention, it is your responsibility to inform us.
Patient Signature *

Clear
Should be Empty:

Adult Patient Questionnaire

EMERGENCY CONTACT

CURRENT HEALTH INFORMATION

LIFESTYLE HABITS

HEALTH HISTORY

CONSENTS