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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
*
Father
Mother
Spouse
Sibling
Son/Daughter
Friend
Other
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
Terrible
Fantastic
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
No pain
Extreme pain
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?
Less than 10
10-20
20-30
30-40
More than 40
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.)?
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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
*
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