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Marital Status
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Live with
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Occupation
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Employer
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How did you hear about this clinic?
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What are your most important health problems?
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2.
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3.
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4.
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Do you have family history of...
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Have you ever been hospitalized?
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1.
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2.
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3.
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Any car accidents
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1.
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2.
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3.
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Any broken bones or dislocations?
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1.
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2.
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3.
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Were you ever knocked unconscious?
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Have you ever had a lapse in memory?
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How serious are you about getting well?
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Would you prefer:
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Are you willing to follow a program?
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Are you willing to take supplements?
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Are you willing to make dietary changes?
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Are you willing to do moderate exercise?
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Willingness to stay health after initial care
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Are you familiar with Applied Kinesiology?
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Have you ever been treated by a chiropractor?
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Results?
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Have you ever been treated by a naturopath?
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Results?
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Please rate your stress level:
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Are you currently seeing any practitioners?
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Please list
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Toxic Profession Past or Present
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1.
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2.
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3.
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Major Psychological Trauma
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1.
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2.
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3.
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Serious Infections/Diseases
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1.
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2.
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3.
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Long periods of prescriptions or street drugs?
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1.
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2.
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3.
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Long visits in foreign country?
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1.
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2.
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3.
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Allergies?
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Food
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Drug
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Environmental
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Current Medications
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Other:
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Please list any vitamins:
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additional...
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Typical breakfast
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Typical lunch
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Typical dinner
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Snacks & Drinks
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Main interests and hobbies:
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additional...
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Do you exercise?
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What kind?
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How often?
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Do you avg. 7-8 hrs sleep per night?
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Do you sleep well?
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Awaken rested?
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When is your energy level best and worst?
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Do you have a supported relationship?
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Do you eat out often?
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Do you drink:
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Do you take vacations?
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Do you enjoy your work?
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Do you watch television?
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How many hours?
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Do you drink alcohol?
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How many per week?
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Do you smoke?
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How much a day for how long?
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Do you have a religious or spiritual practice?
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If yes, what?
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Have or Have Had in the Past
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Appendicitis
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Polio
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Whooping Cough
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Anemia
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Measles
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Mumps
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Chicken Pox
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Alcoholism
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Epilepsy
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HIV
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Chills
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Multiple Sclerosis
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Convulsions
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Loss of Sleep
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Fainting
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Loss of Weight
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Fever
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Neuralgia
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Sweats
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Treated for Emotional Problems
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Mood Swings
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Considered/Attempted Suicide
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Poor Concentration
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Depression
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Anxiety or Nervousness
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Tension
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Memory Problems
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Hypothyroid
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Hypoglycemia
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Excessive Thirst
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Heat or Cold Intolerence
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Diabetes
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Excessive Hunger
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Night Sweats
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Chronic Fatigue Syndrome
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Chronic Swollen Glands
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Reaction to Vaccinations
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Chronic Infections
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Slow wound healing
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Seizures
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Muscle weakness
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Loss of Memory
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Vertigo or Dizziness
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Paralysis
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Numbness or Tingling
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Easily Stressed
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Loss of Balance
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Trouble swallowing
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Change in thirst
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Nausea
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Vomiting blood
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Blood in stool
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Abdominal pain/cramps
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Belching or passing gas
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Black stool
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Liver trouble
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Heart Burn
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Change in appetite
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Constipation
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Diarrhea
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Gallbladder Trouble
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Ulcer
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Hemorrhoids
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Poor digestion
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Poor appetite
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Pain on Urination
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Frequent urination at night
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Increased frequency (urination)
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Inability to hold urine
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Kidney Stones
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Blood in Urine
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Kidney infection
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Prostrate trouble
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Discharge or sores
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Female
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Age of first menses
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Age of last menses
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Length of cycle (days)
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Duration of menses (days)
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Painful menses
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Heavy of excessive flow
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PMS
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If yes what symptoms
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Endrometriosis
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Ovarian cysts
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Difficulty conceiving
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Are cycles regular
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Bleeding between cycles
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Pain during intercourse
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Clotting
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Discharge
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Herpes
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Venereal Disease
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IUD
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Birth Control
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What type?
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Number of pregnancies
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Number of live births
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Number of miscarriages
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Number of abortions
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Hot Flashes
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Lump in breast
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Have you had a mammogram?
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Last Pap smear date?
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Was it normal?
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Muscles/Joints/Bones
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Backache
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Stiff neck
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Foot Trouble
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Swollen Joints
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Pain between shoulders
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Tremors/Twitching
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Painful tailbone
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Arm Trouble
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Skin
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Rashes
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Lumps
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Eczema or Hives
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Itching
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Acne or Boils
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Hair Loss
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Color Change
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Bruise easily
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Head Eyes Ears Nose Throat
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Headaches
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Frequent Colds
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Migraines
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Stuffy Nose
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Head Injury
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Runny Nose
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Jaw/TMJ problemes
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Sinus Problems
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Spots in Eyes
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Nose Bleeds
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Impaired Vision
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Hay Fever
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Bluriness
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Loss of Smell
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Colorblindness
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Frequent Sore Throat
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Double Vision
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Teeth Grinding
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Cataracts
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Gum Problems
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Glasses or Contacts
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Dental Cavities
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Eye pain/strain
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Sores on tongue or lips
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Tearing or Dryness
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Hoarseness
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Glaucoma
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Difficulty Swallowing
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Impaired Hearing
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Goiter
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Earaches
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Swollen Glands
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Ringing
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Dizziness
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Respiratory
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Cough
|
Shortness of Breath
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Spitting Up Blood
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Shortness of breath at night?
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Asthema
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Tuberculosis
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Pneumonia
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Spitting up Phlegm
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Emphysema
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Wheezing
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Pain on Breathing
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Bronchitis
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Cardiovascular
|
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Heart Disease
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Varicose Viens
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High Blood Pressure
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Murmurs
|
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Low Blood Pressure
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Blood Clots
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Pain Over Heart
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Phlebitis
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Poor Circulation
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Rheumatic Fever
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Rapid Heart
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Swelling in Ankles
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Slow Heart
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Palpitations/Fluttering
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Stroke
|
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Complete if you have musculoskeletal pain
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Area
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Intensity
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Area
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Intensity
|
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Area
|
Intensity
|
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Area
|
Intensity
|
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How long has it lasted
|
Is this condition...
|
|
Was this condition caused by an injury/accident?
|
If no when did you first notice it?
|
|
The pain came on...
• • •
|
Describe the pain
• • •
|
|
Does the pain...
|
When is the pain the worst?
|
|
Numbness or Tingling in...
• • •
|
What makes the pain worse?
|
|
What makes the pain better?
|
Does the pain effect sleeping?
|
|
Does the pain effect your work?
|
|
|
Have you been hospitalized in the last 5 years?
|
If yes for what?
|
|
Major surgery in the last 5 years?
|
If yes for what?
|
|
Have you seen other doctors for this condition?
|
If yes doctors name
|
