Print this form, complete it and bring to your first appointment

 

First /Last Name:
Today's Date:
Address:
Home Phone:
City:
Work Phone:
State:
Zip:
Mobile Phone:

 Occupation / Employer's Name & Address:

Email:

Social Security#

Date of Birth:
        Age:   

Male     Female   
Single     Married     Divorced     Widowed
 

Spouse's Occupation:

No. of Children:

Referred by?

Childhood Years

 
Yes
No
Unsure
 
Yes
No
Unsure
Did you have any childhood illnesses?
Was there any prolonged use of medicine such as antibiotics or an inhaler?
Did you have any serious falls as a child?
Did you suffer any other traumas?
(physical or emotional)
Did you play youth sports?
Were you vaccinated?
Did you have any surgery?
As a child, were you under regular Chiropractic care?
Have you fallen/jumped from a height over three feet? (i.e. crib, bunk bed, tree)
       
Were you involved in any car accidents?
       

Comments:

 

Adult Years

 
Yes
No
 
Weight:
 
Do/did you smoke?
Do/did you drink alcohol?
Have you been in any accidents?

On a scale of 1-10 describe your stress level:
(1 = none / 10 = extreme)

Occupational:
Personal:
Have you had any surgery?
Do/did you play any adult sports?

 

On a scale of Poor, Good, or Excellent describe your:

  Poor Good Excellent
Diet:

Exercise:
Sleep:
General Health:


Addressing The Issues That Brings You To The Office

If you have no symptoms or complaints, and are here for wellness services, please check here:

I wish to have Chiropractic Wellness Services
(Please skip to "Family Health Profile" further below on this form.)

Briefly describe the issue that brings you to the office, including the affect it has had on your life.

 

Other Doctors seen for this problem (please list):

Chiropractor
Medical Doctor
Other

Please check all symptoms you have ever had, even if they do not seem related to your current problem.

Headaches
Pins & Needles in Arms
Dizziness
Numbness in Fingers
Fatigue
Sleeping problems
Diarrhea
Cold Sweats
Mood Swings
Pins & Needles in Legs
Loss of Smell
Buzzing in Ears
Numbness in Toes
Depression
Stiff Neck
Constipation
Sensitive Eyes
Menstrual Pain
Fainting
Back Pain
Ringing in Ears
Loss of Taste
Irritability
Cold Hands
Fever
Problem Urinating
Menstrual Irregularity
Neck Pain
Loss of Balance
Nervousness
Upset Stomach
Tension
Cold Feet
Hot Flashes
Heartburn
Ulcers

List any medications you are taking:

Family Health Profile:
Please mention below any health conditions or concerns you may have about your:

Children:
Spouse:
Mother:
Father:
Brother(s):
Sister(s):
Others:

 

The statements on this form are accurate to the best of my recollection and I agree to allow this office to examine me for further evaluation:


Signature: ___________________________         Date: ____________

 

TERMS OF ACCEPTANCE

When one seeks chiropractic health care and is accepted for such care, it is essential for both doctor and patient to be working towards the same objective.

Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be used to attain it.

Adjustment: An adjustment is the specific application of forces to facilitate the body's correction of vertebral subluxation. The chiropractic method of correction is by specific adjustments of the spine.

Health: A state of optimal physical, mental, and spiritual well being, not merely the absence of disease or infirmity.

Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body's innate ability to express its maximum health potential.

Chiropractors do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal examination, non-chiropractic or unusual findings are encountered, you will be advised.

Regardless of what the disease is called, chiropractors do not offer to treat it. Nor do chiropractors offer advice regarding treatment prescribed by others. The chiropractor's only practice objective is to eliminate a major interference to the expression of the body's innate wisdom. The only method is specific adjusting to correct vertebral subluxations.

I, (print name) have read and fully understand the above statements.

All questions regarding the doctor's objectives pertaining to my care in this office have been answered to my complete satisfaction.

I therefore accept chiropractic care on this basis.


Signature: ___________________________         Date: ____________
(signature of parent or guardian if patient under 18 years old)