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Patient Data
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Date
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Medical History
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Referred By
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First Name
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Last Name
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Email
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Mailing Address
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Work Phone Number
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Home Phone Number
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Age
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Birth Date
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Social Security Number
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Number of Children
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Occupation
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Empolyer
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Social History
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Marital Status
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Spouse's Name
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Spouse's Occupation
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Spouse's Employer
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Spouse's Health Status
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Emergency Contact
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Emergency Contact Phone Number
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Current Complaints
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Nature of Injury
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Please Describe
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Date of Injury
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Date Symptoms Appeared
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Have you ever had the same condition? Yes / No
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If yes, when?
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Have you ever been under chiropractic care? Yes / No
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List of other practitioners seen for this injury/condition
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If yes, please describe
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Insurance Information
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Name of party responsible for payment
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Phone
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Do you have health insurance? Yes / No
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Name of Company
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If an auto accident, please provide:
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Insurance Company Name
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Contact Person
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Phone:
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Claim Number
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Medical History
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Have you been treated for any conditions in the last year? Yes / No
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If yes, please describe
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Date of last physical exam
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Is there a chance that you are pregnant? Yes / No
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Have you had x-rays taken? Yes/No
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If yes, where?
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Medications
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Have you ever:
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Broken bones? Yes / No
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Been hospitalized? Yes / No
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Been in an auto accident? Yes / No
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Had sprains/strains? Yes / No
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Been struck unconscious? Yes / No
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Had surgery? Yes / No
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Notes from Above:
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Family History
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Father's MH
• • •
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Comments
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Mother's MH
• • •
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Comments
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Sibling(s)' MH
• • •
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Comments
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Grandparent's MH
• • •
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Comments
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Children(s)' MH
• • •
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Comments
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Current Pain:
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Location of Pain
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Type of Pain(s)
• • •
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Do you experience pain every day? Yes / No
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Does your symptoms interfere with everyday life? Yes / No
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Does your pain wake you up at night? Yes / No
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Are your symptoms worse during certain times of the day? Yes/No
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Do changes in weather affect your symptoms? Yes / No
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Do you wear orthotics? Yes / No
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Do you take vitamin supplements? Yes / No
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What activities aggravate your symptoms?
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Habits
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Alcohol
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Comments
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Coffee
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Comments
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Tobacco
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Comments
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Drugs
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Comments
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Exercise
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Comments
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Sleep
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Comments
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Appetite
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Comments
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Soft Drinks
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Comments
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Water
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Comments
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Sugary Foods
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Comments
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Artificial Sweeteners
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Comments
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Have you ever suffered from:
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Alcoholism Yes / No
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Allergies Yes / No
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Anemia Yes / No
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ArteriosclerosisYes / No
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Arthritis Yes / No
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Asthma Yes / No
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Back Pain Yes / No
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Breast Lump Yes / No
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Bronchitis Yes / No
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Bruise Easily Yes / No
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Cancer Yes / No
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Chest Pain/Conditions Yes / No
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Cold Extremities Yes / No
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Constipation Yes / No
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Cramps Yes / No
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Depression Yes / No
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Diabetes Yes / No
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Digestion Problems Yes / No
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Dizziness Yes / No
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Ears Ring Yes / No
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Excessive Menstruation Yes / No
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Eye Pain or Difficulties Yes / No
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Fatigue Yes / No
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Frequent Urination Yes / No
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Headache Yes / No
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Hemorrhoids Yes / No
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High Blood Pressure Yes / No
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Hot Flashes Yes / No
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Irregular Heart Beat Yes / No
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Irregular Cycle Yes / No
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Kidney Infections Yes / No
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Kidney Stones Yes / No
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Loss of Memory Yes / No
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Loss of Balance Yes / No
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Loss of Smell Yes / No
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Loss of Taste Yes / No
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Lump in Breast Yes / No
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Neck Pain or Stiffiness Yes / No
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Nervousness Yes / No
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Nosebleeds Yes / No
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Pacemaker Yes / No
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Polio Yes / No
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Poor Posture Yes / No
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Prostate Trouble Yes / No
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Sciatica Yes / No
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Shortness of Breath Yes / No
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Sinus Infection Yes / No
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Sleep problems or Insomnia Yes / No
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Spinal Curvatures Yes / No
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Strokes Yes / No
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Swelling of ankles Yes / No
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Swollen Joints Yes / No
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Thyroid Condition Yes / No
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Tuberculosis Yes / No
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Ulcers Yes / No
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Varicose Veins Yes / No
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Venereal Disease Yes / No
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Other:
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