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Occupation
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Employer/School Name
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Marital Status
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Name of Spouse / Significant Other
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Name of your Primary Care Physician or OB/GYN
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Phone Number of Primary Care Physician or OB/GYN
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How did you hear about us?
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Other, who referred you?
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Would you like access to our online portal?
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Chiropractic Experience
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Have you seen a chiropractor before?
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If yes, who?
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Why were you treated?
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Were you helped?
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When were you treated?
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Were x-rays taken?
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Health Lifestyle and Family History
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Family History
• • •
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Do you exercise?
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How often?
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Do you smoke?
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How many packs/day?
/
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Do you drink alcohol?
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How often?
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Do you take supplements (vitamins, herbs)?
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If yes, what?
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What sports or activities did you participate in growing up?
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Are you currently pregnant?
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If so, how far along?
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Functional Assessment
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Rate your pain from 1-10 when:
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Sleep / Rolling
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Sitting
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Reading
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Computer Use
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Sit to Stand
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Standing
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Dressing
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Driving
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Yard work / Housework
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Walking
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Bending / Lifting
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Exercise / Sports
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Pushing
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Pulling
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Trauma History
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Prior Car Accidents
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Not Applicable
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Date of Accident #1
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Type of Impact
• • •
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How did the accident happen?
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What areas were injured?
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Speed
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With whom did you treat these injuries?
• • •
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Were x-rays taken?
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Date of Accident #2
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Type of Impact
• • •
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How did the accident happen?
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What areas were injured?
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Speed
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With whom did you treat these injuries?
• • •
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Were x-rays taken?
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Prior Sports Injuries
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Not Applicable
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Date of Injury #1
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What areas were injured?
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How did the injury happen?
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With whom did you treat these injuries?
• • •
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Were x-rays taken?
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Date of Injury #2
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What areas were injured?
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How did the injury happen?
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With whom did you treat these injuries?
• • •
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Were x-rays taken?
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Prior Surgeries
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Not Applicable
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Date of Surgery #1
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What was the reason for the surgery?
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What area of your body did you have surgery?
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Were x-rays taken?
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Date of Surgery #2
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What was the reason for the surgery?
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What area of your body did you have surgery?
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Were x-rays taken?
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Additional Injuries
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Not Applicable
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Date of Incident #1
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What areas were injured?
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How did the injury happen?
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With whom did you treat these injuries?
• • •
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Were x-rays taken?
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Date of Incident #2
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What areas were injured?
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How did the injuy happen?
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With whom did you treat these injuries?
• • •
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Were x-rays taken?
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Anything else we need to know?
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