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585-670-0020
Weight Loss
Chiropractic
Auto Accident Recovery & Whiplash
Back Pain
Neck Pain
Carpal Tunnel
Improved Wellness
Joint & Chronic Pain Elimination
Sciatica
Decompression Therapy
X-Rays for Chiropractic Services
Migraines & Headaches
Knee Pain
Decompression
Education
Orthotics
Choosing the Right Shoes
Understanding Foot Pronation
Foot Scans for Custom Orthotics
Orthotics for Lower Back Pain
Understanding Plantar Fasciitis
Treating Heel and Foot Pain
Our Blog
Neuropathy
Can Peripheral Nerves Heal?
What is Peripheral Neuropathy?
Our Safe, Effective Neuropathy Protocol
Forms
MLS Laser Therapy
About
Office Locations & Directions
Dr. Nate Riddle
Office Hours
Testimonials
Vaccine Education
Wellness Presentations
Our Services
Our Services
Chiropractic
Nutrition
Orthotics
Neuropathy
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Confidential Patient History
Name
Home Phone
Work Phone
Cell Phone
Address
Date of Birth
Age
Marital Status
Names/Ages of Children
Occupation
Employer
Employer Address
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.
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