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Who may we thank for referring you?
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How did you hear about us?
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Presenting Complaint
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Have you had chiropractic before?
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Any diagnosis given?
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Reason for today’s visit
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How long have you had this
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Have you had it in past?
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Level of pain
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Is your condition getting
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If yes,describe when
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Is the problem aggravated by
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Is the problem helped by
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Diagnosing physician
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Date of last physical exam
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Other Physicians treating you?
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Being treated for other problems
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If yes,List problem
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LIst your medications
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PreviousTreatments
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List any herbs you are taking
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Reason for medication
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Inoculation had last year
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List supplements you are taking
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Medical History
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List surgeries and date
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Did you ever have/had
• • •
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More than 2 Course of antibiotic
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Travelled outside country
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Accident/traumas with date
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Which countries?
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Inoculations you had
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Musculoskeletal
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Head, Ears, Nose, Mouth ,Throat
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Any numb areas?
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Eyes
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Taken adrenal corticosteroids
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Skin and Hair
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General Symptoms
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Cardiovascular
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Frequency of Bowel Movements
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Cardiovascular Continued
• • •
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How often you urinate at night
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Sleep
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Respiratory
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Hours you sleep
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Gastrointestinal
• • •
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Urinary and Genital
• • •
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Unusual birth history
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Family History
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Father Still Alive?
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Mother Still Alive?
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Father Cause of Death
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Mother Cause of Death
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Father's MH
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Mother's MH
• • •
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What type of Cancer?
• • •
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What type of Cancer?
• • •
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ALL Sibling's MH
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ALL Grandparent's MH
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Social History
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Marital Status
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Occupation
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Living Arrangements
• • •
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Potential Environmental Pathogen
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Diet
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Comments
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Caffeine
• • •
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Comments
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Alcohol
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Comments
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Recreational Drug Use
• • •
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Comments
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Sexual Activity
• • •
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Sexually abused
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Emotional
• • •
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Treated for emotional Problems
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Emotionally abused
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Physically abused
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Unusual Stressful Experience
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Other emotional problems
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Holmes-Rahe Stress Inventory
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Which has happened in the last year?
• • •
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Holmes-Rahe Stress Score
• • •
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Women Only
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Pregnancy and Gynecology
• • •
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Date of last menses
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Pregnancy/Gynecological Problem
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Method of birth control
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Date of last pap test
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Other
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