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ADULTS ONLY
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PEDIATRICS GO TO THE PREVIOUS PAGE
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Driver's License #
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Employer
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Occupation
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Name of Spouse
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Spouse's Employer
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Occupation
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Reason that you are coming to the office today?
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Have you ever been under chiropractic care?
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If yes, how long ago:
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Name of Previous Chiropractor:
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Your problem(s) today the result of ANY accident
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If yes, How long ago?
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Please explain what type of accident:
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Conditions that you have had in the past
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Conditions that patient has Currently
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Conditions that patient never has had
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System Review - General
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Eyes, ears, nose, throat
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Skin
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Pulmonary/lungs
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Cardiovascular
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Muscle/joint/bone
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Gastrointestinal
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Genitourinary
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Neurologic
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Endocrine
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Women only
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PERSONAL/FAMILY HISTORY - SELF Illness/Condition
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Other, please specify
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Grandparents - Illness/Condition
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Other, please specify
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Father - Illness/Condition
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Other, please specify
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Mother - Illness/Condition
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Other, please specify
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Brother - Illness/Condition
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Other, please specify
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Sister - Illness/Condition
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Other, please specify
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List orthopedic (spine, joint, bone) surgeries
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Reason for the surgery
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Date of surgery
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List OTHER types of surgery with reason and date
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SOCIAL HISTORY - Smoking
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How often
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Do you drink alcohol?
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If yes, how often
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Do you use recreational drugs?
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If yes, how often
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Level of education?
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Problems affecting daily life in following ways
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Pushing a shopping cart
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Sitting to Standing
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Lying to sitting
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Sitting for more than ___ min/hrs
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Affects while sitting for the time specified?
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Lying down for over ____ min/hrs
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Affects while lying down for the time specified?
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Walking more than ____ min/hrs
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Affects while walking for the time specified?
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Driving more than ______ minutes/hrs
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Affects while driving for the time specified?
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Standing more than ______ minutes/hours
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Affects while standing for the time specified?
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Sleeping
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Lifting babies/children
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Lifting groceries/items over ___lbs
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Affects while lifing items for the lbs specified
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Bathing/dressing myself
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Combing my hair
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Rolling over in bed
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Exercise more than _____ minutes/hrs
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Affects while exercising for the time specified?
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Housework (vacuum, laundry, etc.)
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Yard work
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Work Activity (list _____________)
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Affects while doing the work activity specified
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Work on computer
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Climbing stairs
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Reaching to put items on shelf
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Hobbies (identify)____
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Affects while doing the hobbies specified?
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Use my hands to _____________
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Affects while using hands to perform something
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Other activities that you are unable to perform
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