1
Name
Birth
date Age
Address
City State Zip
Gender #
of Children
Ages
of children
Social
Security #
E-Mail
Address
Employer
Work
Address
Type
of Work
Marital
status
Spouse's
Name
Home
# Work
#
Other
(cell) #
Best
time and place to reach you
IN
CASE OF EMERGENCY, CONTACT:
Name Relationship
Home
# Work
# |
2
What
is the main reason for contacting
our office?
Most
patients are referred to our
office by a caring family member
or friend. What made you decide to
visit our office?
List
details of your selection; family
or friend name, advertisement
name..etc
Research
shows that your spine and nervous
system should be checked
regularly. How many times
have you visited a chiropractor in
your lifetime?
Has
any other member in your family
had their spine and nervous system
checked?
Poor
posture leads to poor health, and
often indicates a spinal problem.
How would you rate your posture?
1
is poor, 9 is excellent
Stress
can cause or accelerate spinal
damage. Rate your stress level
over the last 90 days.
1
is low, 9 is high
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3
INSURANCE
Although
most health insurance is for
emergency care rather then
healthcare, many companies offer
chiropractic benefits. Do you have
insurance that you believe will
pay for a portion of your care?
Insurance
Co. Group
# (plan/policy #)
Policy
holder Relationship
to patient
Insured
Social Security # Date
of birth Employer
Insurance
Co. Address
Phone
#
In
office payment method:
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4
GOALS
FOR MY CARE
People
see Chiropractors for a number of
reasons. Some go for relief of
pain, some to correct the cause of
pain and others to achieve overall
optimal health. Your Doctor will
weigh the needs and desires when
recommending your treatment
program. Please check the type of
care desired so treat we may be
guided by your wishes whenever
possible.
Relief
Care –
Symptomatic relief of pain or
discomfort
Corrective
Care –
Correcting and relieving the cause
of the problem as well as the
symptoms
Wellness
Care –
Helping the body to achieve the
highest state of health possible
with Chiropractic care
I
want the Doctor
to select the
type of care appropriate for my
condition |
5
HEALTH
CONCERNS
Please
check each of the diseases or
conditions that you have now or
have had in the past. While they
may seem unrelated to the purpose
of the appointment, we consider
your complete health important to
us and may assist us in
determining your care plan.
|
Headaches
Pins
& needles/numbness
Fatigue/sleeping
problems
Diarrhea/Constipation
Cold
Sweats
Ringing
in ears
Depression
Fainting
- Dizziness
Hernia
Herniated
Disk
Kidney
Disease
Stroke
Rheumatoid
Arthritis |
Cold
hands/feet
Problems
urinating
Nervousness
Digestive
problems
Hot
flashes
Ulcers
AIDS
- HIV
Arthritis
Asthma
Cancer
Diabetes
Emphysema
Skin
changes/conditions |
Epilepsy
Fractures
Heart
Disease
Liver
Disease
Miscarriage
Multiple
Sclerosis
Osteoporosis
Pacemaker
Pinched
Nerve
Prostate
problems
Thyroid
problems
Tumors
- growths
Sinus
problems
|
ADD/ADHD
Neck
pain
Shoulder
pain
Mid
back pain
Lower
back pain
Arm
- Leg pain
Other
FOR
WOMEN
Are you
pregnant? Y N
Are you
nursing? Y N
Taking
birth control? Y N
Having
painful periods? Y N
Irregular
cycles? Y N |
6
HEALTH
HABITS
Do you
smoke? Y N packs/day
Do you
exercise regularly? No Moderate Daily
Supplements/Vitamins
|
Do you
drink alcohol? Y N drinks/day
Do you
drink coffee? Y N cups/day |
| Prescriptions
or over the counter medications
may cause various side effects,
hide the severity of health
problems, and hinder the body’s
ability to heal. What medications
are you currently taking? |
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me to your email list
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