Patient History

  After filling out this form, please print it and bring it with you on your first visit to our office.  If you wish, you
  may print out this form first, then fill it out later with pen.
 
 
Date (dd/mm/yy):          
 How did you hear about us?
 

Name 

Home Phone  Work Phone 
Address  City  State  Zip
SSN  Sex  Age 
Marital Status  DOB     
Employer's Name and Address
Explain Occupation (actual job duties)
Name of Spouse  Spouse's Employer and Phone 
Nearest Relative  Phone of Nearest Relative 
 

 Are you here as a result of an injury?
 Yes No

 Do you think you might be pregnant? Yes No
 Have you ever seen a chiropractor?    
 Yes No
 When? Doctor's Name
 Describe your major complaint
 What movements, positions, or activities aggravate this condition? 

 Have you been treated for this condition before?  Yes No
 If yes, when?  What was done?  
 
PERSONAL HISTORY:
 Illness or Conditions 
 Surgeries                 
 Fractures     Previous Injuries
 Medications  Supplements      
 Last Medical Exam Date (dd/mm/yy)  MD's Name         
 Hobbies/Recreational Activities
 
Please check all that apply:  Do you have pain in:
  No symptoms, check-up   Poor Appetite   Neck  
  Headaches   Constipation   Shoulder   Right Left
  Blurred Vision   Loose Stool   Arm   Right Left
  Dizziness   Excessive Gas   Elbow   Right Left
  Low Energy   Heart Palpitations   Hand   Right Left
  Weakness   Sexual Impotency   Upper Back  
  Indigestion/Heartburn   Hot Flashes   Mid Back  
  No symptoms, check-up   Inner tension   Lower Back  
  Throat Lump/Constriction   Menstruation   Hip   Right Left
  Numbness     Thigh   Right Left
  Fainting/Light-headed  Do you have a history of:   Knee   Right Left
  Swelling   Heart Disease   Calf   Right Left
  Sinus Problems   Stroke   Ankle   Right Left
  Insomnia   Kidney Stones   Foot   Right Left
  Poor Memory   Urinary Tract Infection   Chest  
  Excessive Swelling     Abdomen  
 Pain in Morning  Afternoon   Night   Kidney Area