WELCOME TO OUR OFFICE PATIENT:

Last Name: First Name:

Gender: M F Date of Birth:__/__/__ Age:

Home Address:

City:

SS#:

Home Phone #: _

Employer Name:

Employer Address:

City:

State: Zip:.

Work Phone #:

Occupation:

State:

Middle:

Apt #:

Email #:

Cell #:

Apt#:_

_ Zip:

SPOUSE or GUARDIAN:

Last Name:

Employer Name:

Date of Birth: /

First Name:

Work Phone #:

SS#:

Middle:

EMERGENCY Name and address of nearest relative or friend not living with you:

Last Name: First Name: Middle:

Home Phone #:

Relation to Patient:

Primary Care Physician:

Phone #:

Work Phone #:

What is the main health problem you want to talk to the doctor about?

How long have you had this condition?

What activities aggravate your condition?

Is this condition getting worse? □ Yes □ No □ Comes and goes □ Constant Number of episodes per day per week.

Condition interfering with your □ work □ sleep □ daily routine □ other

per mo.

Drugs you now take: □ Nerve pills □ Pain killers □ Muscle relaxers □ "Pep" pills □ Tranquilizers □ Birth control pills □ None □ Other

MEDICATION DOSAGE REASON DOCTOR

HAVE YOU EVER: YES NO

Been knocked unconscious? □ □

Used a cane, crutch, or other support? □ □

Been treated for a spine or nerve disorder? □ □

Had any fractures or dislocations? Q □

Had any accidents or falls? □ a

Been hospitalized for other than surgery? □ □

Have you ever been in an auto accident? □ □

DESCRIBE BRIEFLY:

HEALTH REPORT

Do you:

Now take vitamins or minerals? □ Yes □ No

Think you may need vitamins/minerals? □ Yes □ No

Have an allergy to drug or food? □ Yes □ No Type

Does any member of your family have: (please circle)

arthritis heart disease cancer diabetes epilepsy lung disease emotional problems intestinal disorders

scoliosis spinal arthritis neck or back pains abnormal spinal development

other health problems? Yes / No Whom? Father Mother Sister Brother Aunt Uncle

/ CERTIFY THAT ALL INFORMATION GIVEN IS TRUE AND CORRECT. I hereby authorize the release of any information required by this office. I also authorize my benefit payments to be made directly to this clinic. If my current policy prohibits direct payment to doctor, then I hereby also instruct and direct my insurance company to make out the check to me and mail it to this office. I under stand that I am financially responsible for all services rendered. I agree that if my treatment here is suspended or terminated, fees become immediately due and payable. All X-rays are the property of this Chiropractic Center.

SIGNATURE OF PATIENT OR GUARDIAN

FOR OFFICE USE ONLY, DO NOT WRITE IN THIS SPACE

PRIMARY COMPLAINT

Exact description of problem

Character of pain (c

ircl

e appropriate):

Hurt

Ache

Throbbing

Stabbing

Pull

ing

Cramp

Spasm

Burning

Crawling

Soreness

Prick

ling

Numbness

Stiffness

Loss o

f ROM

Constant

Intermittent

Radiating to

Severity 12345678910

Worse in:

Morning

Evening

Night

Worse with:

Exercise

Inactivity

Movement

Cold

Heat

Other

Better with:

Exercise

Rest

Cold

Heat

Pain Pi

lls

Other

Related area of pain

Onset (how & when)

Date

Reoccurrence

Date

Same

Related to f

all or accident (describe)

Did f

all or accident occur at

Home

Was Pt i

n Auto Accident

Better

Worse than before

Date

Work

Other,

Date

Other circumstances assoc. with problem (complications)

SECONDARY COMPLAINT

Exact description of problem

Character of pain (c

ircl

e appropriate):

Hurt

Ache

Throbbing

Stabbing

Pull

ing

Cramp

Spasm

Burning

Crawling

Soreness

Pri

ckli

ng

Numbness

Stiffness

Loss o

f ROM

Constant

Intermittent

Radiating to

Severity 12345678910

Worse in:

Morning

Evening

Night

Worse wit

h:

Exercise

Inac

tivi

ty

Movement

Cold

Heat

Other

Better with:

Exercise

Rest

Cold

Heat

Pain Pi

lls

Other

Related area of pain

Onset (how & when)

Date

Reoccurrence

Date

Same

Better

Worse than before

Related to

fall or accident (describe)

Did f

all or accident occur at

Home

Was Pt i

n Auto Accident

_Date_

Work

Other.

Date

Other circumstances assoc. with problem (complications)

THIRD COMPLAINT

Exact description of

problem

Character of pain (c

ircl

e appropriate):

Hurt

Ache

Throbbing

Stabbing

Pulling

Cramp

Spasm

Burning

Crawling

Soreness

Pric

klin

g Numbness

Stiffness

Loss of ROM

Constant

Intermittent

Radiating to

Severity

1 23456789 10

Worse in:

Morning

Evening

Night

Worse with:

Exercise

Inac

tivi

ty

Movement

Cold

Heat

Other

Better with:

Exercise

Rest

Cold

Heat

Pain Pi

lls

Other

Related area of pain

Onset (how & when)

Date

Reoccurrence

Date

Same

Better

Worse than before

Related to f

all or accident (describe)

Did f

all or accident occur at

Home

Was Pt i

n Auto Accident

_Date_

Work

Other.

_Date_

Other circumstances assoc. with problem (complications)

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