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How did you find us?
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Have you seen a Chiropractor before?
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Occupation
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Employer/School Name
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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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Any blood-born illnesses?
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If yes, description and date
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Past hospitalizations?
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If yes, description and date
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Past surgeries?
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If yes, description and date
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Root canals?
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Which teeth?
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Illnesses you've had:
• • •
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Vaccination you have had
• • •
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Illnesses in your family
• • •
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Recurrent Infections or Illnesses
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List of supplements
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List of medications
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Coffee
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What and how often?
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Cigarettes
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How much?
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Smokeless tobacco
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How many?
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Alcohol
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How often?
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Soda
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How much?
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How much water do you drink?
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Taken corticosteroids?
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More than 2 course of antibiotics?
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Travelled outside the country?
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Which countries?
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Unusual birth history?
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Please describe
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How is your sleep?
• • •
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Hours you sleep?
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Unusual Stressful Experience?
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Describe:
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For Children
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Mother's health during pregnancy
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Mother's health during delivery
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Mother's health post-natally
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Vaginal birth?
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Medication used during pregnancy/delivery
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Medications given to child at birth
• • •
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Breast fed?
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Until what age?
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If formula-fed or supplemented, what kind?
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For Women
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Are you currently pregnant?
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Method(s) of birth control
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Mammogram
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Date of last mammogram
/
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Mammogram result
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Bone density scan
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Date of last bone density scan
/
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Bone density result
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Yes, Have Previous Motor Vehicle Collisions
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No Previous Motor Vehicle Collisions
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When Was The Injury?
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Type of Impact
• • •
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What areas were injured?
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Who Treated You?
• • •
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Do You Still Have Pain/Discomfort?
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If Yes: Please Indicate Location Of Symptoms.
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Additional Motor Vehicle Collisions?
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Prior Sports Related Injury?
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If Yes: Please Describe
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Prior Surgeries?
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Date of Surgery
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What area of your body did you have surgery?
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