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Personal information
Patient name *
Gender *
Date of birth *
Employer
Who referred you? (How did you find us?) *
Contact information
Street address *
Apartment No.
Buzzer No.
City *
Postal/Zip code *
State/Province *
Home phone *
 
Business phone
 
Cell phone
 
Email address *
It is our pleasure to be of service to you. Our commitment is to promote the highest quality of health and well-being through natural chiropractic methods.
Please complete the confidential New Member Health and Wellness Record fully and accurately. The more we know about your overall health, the better we can help you.
Doctors of Chiropractic are trained to detect and correct vertebral subluxations. Please respond to this questionnaire thoroughly to help us determine potential causes and effects of subluxations in your case.
EXPERIENCE with Chiropractic Care
Who referred you to this office?
Have you ever been adjusted by another Chiropractor? *
Reasons for those visits?
Were X-rays taken?
Did your family receive chiropractic care?
Chiropractor's Name
Approximate date of last visit:
Additional Personal Informations
Height:
Weight:
Marital Status: *
Name of Spuse / Significant Other:
Goals for my care
People see chiropractors for a variety of reasons. Some go for pain relief, some to correct the cause of the pain and others for correcting whatever is malfunctioning in their bodies. Your doctor will weigh your desires when making recommendations. Please check the type of care desired so that we may be guided by your wishes.
Relief care - symptomatic relief of pain or discomfort
Corrective care - correcting and relieving the cause of the problem as well as the symptoms
Comprehensive Care - bring whatever is mulfunctioning in the body to the highest state of health possible with chiropractic adjustments
I want the doctor to help me select the type of care
Purpose of this appointment?
Describe the purpose of this visit: *
Is the purpose of this appointment related to: *
Please explain further:
If a specific problem exists:
How long have you had this problem?
Have you had the same before?
What activities aggravate this condition?
Has this condition
Does this condition interfere with:
Please explain:
Have you seen any other health care providers for diagnosis or management of this condition? *
If yes, complete the following:
Practitioner's Name:
Type of Care:
Date:
Results:
My Health Condition
Please check each of the disease or condition that you have now or have had in the past. While some conditions may seem unrelated to the purposes of this appointment, they can affect diagnosis, care plan, and possibility of being accepted for care or referred to another practitioner.
GENERAL
Allergies
Convulsions
Fatigue
Headache
Loss of Sleep
Loss of Weight
Anxiety / Depression
Numbness
Cancer
Diabetes
Thyriod problems
Epilepsy
Hyperactivity
Liver trouble
MUSCLE AND JOINT
Arthritis
Hernia
Low back pain
Neck pain
Pain between shoulder blades
Poor Posture
Swollen joints
Gout
Polio
NUMBNESS OR PAIN IN:
Shoulders
Upper arms
Hands
Legs
Feet
GASTRO-INTESTINAL
Constipation
Diarrhea
Digestive dysfunction
Liver trouble
Ulcers
Gall Bladder trouble
Hemorrhoids
EYES, EARS, NOSE, TROAT
Asthma
Frequent Colds
Crossed Eyes
Deafness
Ear Infections
Ringing in the ears
Eye Pain
Visions problems
Nasal obstruction
Sinus infection
CARDIO-VASCULAR
Stroke
High blood pressure
Poor circulation
Irregular heart beat
Ankle swelling
Anemia
Arteriosclerosis/Atherosclerosis
RESPIRATORY
Irregular breathing
Dizziness
Chronic cough
Emphysema
Wheezing
GENITO-URINARY
Painful urination
Bed-wetting
Blood in urine
Prostate trouble
Veneral disease
WOMEN ONLY
Irregular cycle
Menstrual cramps
Excessive menstruation
Are you pregnant
Sources of Spinal Stress
To help us determine the cause of your problem, please indicate, on this page and the next, potential sources of spinal trauma.
General Physical Trauma
Falls - (Details and Dates)
As an infant or child
Down stairs
On ice
Sports impacts
Physical fight
Other
Auto Accidents
Have you ever, even as a passenger, even if you did not think you were hurt, been involved in car accident, or near collision? If yes, please indicate approximate dates and severity:
Explain here:
Primary Daily Activities
Activities:
Exercise
Sports and leisure
Were you, or are you active in any sports?
Describe:
Have you been hurt or injured in any of these activities?
Describe
Injuries and treatments
With respect to the questions below, please provide details where applicable, including dates;
Have you ever been knocked unconscious?
Have you ever used crutches, a walker, or cane?
Have you had any broken bones?
Have you ever had any impacts, falls, or jolts that you feel specially may have injured your spine?
Have you had extensive dental or orthodontic work performed?
Sprains, strains, dislocations and years;
Surgical operations and years:
Have you ever been hospitalized for any other reasons?
History of Chemical and personal Stress
Medications I am presently taking:
Painkillers
Anti-inflammatories
Muscle relaxants
Blood pressure medication
Stimulants, Anti-depressants
Tranquilizers, anti-anxiety
Blood thinners
Birth control pills
Other
Health Habits
Tobacco
Coffee
Alcohol
Recreational Drugs
Prescription Drugs
Supplements (Vitamins, Minerals, etc.)
Exercise
Sleep
Appetite
Personal Stress Levels
Past *
Present *
70 - 90% of all chronic problems are hereditary ( inherited, family pattern, consistent into family. Please indicate family memebers with past or present back and neck problem. ( Please include children, siblings, parents and grandparents )
Write here: *
TO BE COMPLETED BY THE PATIENT:
PRINT PATIENT'S NAME
WITNESS TO ABOVE SIGNATURE:
EMERGENCY CONTACT
Name:
Emergency Contact Home Phone:
Emergency Contact Cell Phone: