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
Name of Insurance Company (if any)
2nd Insurance
Please describe your major complaint and how it happened
Date Started
Had before?
Please Describe
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
If yes, date
Please describe
If yes, date
Please Describe
If yes, date
Please Describe
Please Describe
List any conditions, tests, or exams in the last 10 years we should know about
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
If you have previously seen a chiropractor, please describe your likes and dislikes (if any), so we may better serve you.
