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Where did you find us?
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Who referred you?
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Which specialists do you see?
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Anything special we need to know
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Employer
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Occupation
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Name of Spouse
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Occupation
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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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Eyes, ears, nose, throat
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System Review - General
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Pulmonary/lungs
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Skin
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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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Daily Living Habits
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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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Do you have stress? What kind?
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Level of education?
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Do you have stress, if so what kind.
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Type of Exercise
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Do you exercise regularly
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Energy
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What position do you sleep?
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Sleep Pattern
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How many hours do you sleep at night?
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Female Only
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Date of last menstrual cycle.
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Are you pregnant?
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Dietary and Weight History
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Are you concerned about your weight?
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What best describes your philosphy?
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My pantry and refrigerator are full of.....
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Have you ever had a eating disorder?
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If yes, what type of disorder?
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What diets have you tried in the past?
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How succesful were you?
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How much TV do you watch a week?
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Contributing Factors for Weight Gain
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Activity Level (pick one)
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What is most difficult about managing weight?
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What type of foods do you crave/eat most?
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How confident are you about losing wt this time?
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How can we assist you with weight loss?
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Do you follow a special diet?
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How much family support do you have?
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Which meals do you eat regularly?
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Other Diet
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What are your common snack foods?
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When do you usually snack?
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Daily consumption of starchs ex:bread,cereal
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What do you mostly drink?
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Daily consumption of vegetables?
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Daily consumption of fruits?
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Fat ex: butter,mayo,oil,ice cream,sour cream
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Dairy ex: milk, yogurt
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Protein ex:meat,fish,poultry,cheese,eggs
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Sweets ex: candy,cake,soda,juice
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