Confidential Patient History Form

Name

Home Phone

Work Phone

Cell Phone

Date of Birth

Age

Marital Status

Names/Ages of Children

Occupation

Employer

SSN

Name of Spouse (parent if minor)

Occupation

Employer

Emergency Contact

Phone

M.D.

Who may we thank for referring you to this office?

Email

Preferred Name (how you would like to be addressed)

Reason for visit

The reason for this visit is a result of

Auto

Work

Fall

Sports

Chronic

Other

Name of Insurance Company (if any)

2nd Insurance

Please describe your major complaint and how it happened

Date Started

Had before?

Please Describe

Is this interfering with your

Work

Sleep

Daily Routine

Sports

Recreation

Other

If so, please explain

Please list each area of your symptoms in order of severity, then rate from 1 (No pain or symptoms) to 10 (worst pain imaginable) that best represents the level of severity.

Health History

Have you had medical care for this?

Yes

No

If yes, date

Please describe

Have you had surgeries/fractures?

Yes

No

If yes, date

Please Describe

Are you taking medication?

Yes

No

If yes, date

Please Describe

Have you had a Family History of Health Conditions

Yes

No

Please Describe

Have you had any difficulty with the following in the past?

Abdominal Pain

Alcoholism

Allergy

Anemia

Arthritis

Asthma

Cancer

Chest Pain

Cold Hands/Feet

Colds/Infections

Colon Trouble

Constipation

Depression

Diabetes

Dizziness

Epilepsy

Fatigue

Gall Bladder

Gout

Gynecological Problems

Hardening of Arteries

Hearing Problems

Heart Disease

Headaches

Hemorrhoids

Mental Disease

Nausea

Nervousness

Pneumonia

Poor Appetite

Prostate Problems

Sciatica

Short of Breath

Sinus Trouble

Sleeplessness

Stress

Stroke

Thyroid Trouble

Ulcers

Varicose Veins

Vision Problems

Weight Gain/Loss

Do you have any difficulty with the following now?

Abdominal Pain

Alcoholism

Allergy

Anemia

Arthritis

Asthma

Cancer

Chest Pain

Cold Hands/Feet

Colds/Infections

Colon Trouble

Constipation

Depression

Diabetes

Dizziness

Epilepsy

Fatigue

Gall Bladder

Gout

Gynecological Problems

Hardening of Arteries

Hearing Problems

Heart Disease

Headaches

Hemorrhoids

Mental Disease

Nausea

Nervousness

Pneumonia

Poor Appetite

Prostate Problems

Sciatica

Short of Breath

Sinus Trouble

Sleeplessness

Stress

Stroke

Thyroid Trouble

Ulcers

Varicose Veins

Vision Problems

Weight Gain/Loss

List any conditions, tests, or exams in the last 10 years we should know about

For Females: Are you pregnant?

Yes

No

Do you take birth control pills?

Yes

No

Health Habits

Alcohol (amount per week)

Tobacco ( packs per day)

Exercise

Work (hours per day)

Coffee (cups per day)

Drugs

Sleep (hours per night)

Vitamins

Personal Goals

What are your favorite hobbies to do now?

How are you current problems affecting these activities or hobbies?

On a scale of 0-10 (0 being the least and 10 being the most) how committed are you to being at your maximum health potential? If not 8-10, please explain

On a scale of 0-10 (0 being the least and 10 being the most) how important is it for your family to be at their optimum health potential? If not 8-10, please explain

How do you want us to handle you problem?

Temporary Relief (Help the symptom, but do not fix the problem)

Maximum Correction (Correct the cause of the problem for maximum stability in the future)

If you have previously seen a chiropractor, please describe your likes and dislikes (if any), so we may better serve you.

Patient’s signature (or parent’s, if minor)

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Confidential Patient History

Reason for visit

Health History

Health Habits

Personal Goals

Appointment Call

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