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First, Last Name
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Date of Birth
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Address
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City
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State/Zip Code
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Cell/Home Phone
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Gender
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Under Age 18
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Employer
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Occupation
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Email Address
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Emergency Contact: Name/Number
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How did you hear about our office?
• • •
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If Referral, please tell us who?
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Who is Responsibile for Payment
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Spouse's Name and Number
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Current Complaint
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Please list your worst complaint
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How did it start?
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How long have you had it
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B) Is it
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A) Is it
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C) What worsens it
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D) What makes it better
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If other, please specify
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E) Is it worse in the
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If other, please specify
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2. Please list your 2nd worst complaint
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F) Is the symptoms
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How did it start?
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B) Is it
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How long have you had it
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C) What worsens it
• • •
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A) Is it
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D) What makes it better
• • •
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E) Is it worse in the
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If other, please specify
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If other, please specify
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CONSENT TO RELEASE INFORMATION
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F) Is the symptoms
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CONSENT TO TREAT A MINOR
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Current Health
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CONSENT TO RELEASE INFORMATION
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Name and phone number of family doctor
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May we update them on your condition?
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Date of late eye exam
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What is your usual blood pressure
/
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List current illnesses/diseases diagnosed with
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Health History
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Please indicate your height and weight
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Any operations/surgeries or medical procedures
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Date
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Date
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Date
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Procedure
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Date
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Procedure
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Serious illnesses/injuries in the past/currently
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Date
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Procedure
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Date
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Procedure
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Date
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Condition
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Date
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Condition
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Any current loss of bowel or bladder control
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Condition
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Any unexplained recent weight loss
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Condition
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Current nutritional problems
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Current seizures/paralysis/speech/vision problem
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Please list any significant family illnesses
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Current fever
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Had spinal X-Rays within the past 5 years
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Medications
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Do you have a pacemaker?
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If yes, when and where
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Do you have any blood, lymph disorders?
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If yes, alert doctor/chiropractic assistant
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List other electrical device you currently wear
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Do you have osteoporosis or rheumatoid arthritis
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Do you Exercise? How Much?
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Are you Pregnant? How many weeks?
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Do you wear arch supports?
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Are you nursing?
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Please select one:
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Allergies
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___pk./week
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If so, how much ___pk./day
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Please select one:
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Have you ever had chiropractic care
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Result of that Treatment
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By whom
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If yes, last date of treatment
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Similar or difference condition
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Have you seen any other medical provider for this condition?
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Goals
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Consent to examine and treat condition
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