INITIAL HEALTH STATUS DATE ______
Name ______Email ______
FIRST INITIAL LAST
Address ______City ______State ______Zip ______
Telephone – Home ______Work/Cell ______
Birthdate ______Age ______Male / Female Status: M / S / W / D / P # of Children ______
Occupation ______Employer ______
Address ______City ______State ______Zip ______
Spouse/Partner’s name: ______Employer ______
Do you have insurance r Yes r No
Primary Care Provider ______Clinic ______
Who may we thank for referring you to our office? ______
The human body is designed to express health and function normally. However, events may occur in life which can interfere with this natural ability. This interference is most commonly the result of vertebral subluxations. Stress that may be physical, chemical or emotional may cause these subluxations. The practice of chiropractic is based on the location and reduction of nerve system interference caused by vertebral subluxations.
DESCRIBE YOUR PROBLEM AND HOW IT BEGAN:
r Headache r Neck Pain r Mid-back pain r Low Back Pain
r Other ______
Is this r Work Related r Auto Related r N/A
Date Problem Began: ______
How Problem Began: ______
How often are your symptoms present? r0 – 25% r26 – 50% r51 – 75% r76 – 100%
Have you had Spinal X-rays, MRI, CT Scan or you area(s) or complaint? r Yes r No
Please Check all of the following that apply to you:
r Recent Feverr Diabetes
r High Blood Pressure
r Stroke (Date______)
r Corticosteroid Use (cortisone, prednisone, etc.)
r Taking Birth Control Pills
r Dizziness/Fainting
r Numbness in Groin/Buttocks
r Cancer/Tumor (explain ______
______
r Osteoporosis
r Epilepsy/Seizures
r Abnormal Weight r Gain r Loss / r Prostate Problems
r Menstrual Problems
r Urinary Problems
r Currently Pregnant, # weeks ______
r Marked Morning Pain/Stiffness
r Pain Unrelieved by Position or Rest
r Pain at night
r Visual Disturbances
r Surgeries ______ies ______
______
r Medications ______
r Vitamins/Supplements ______
r Other Health Problems (Explain) ______
Family History: r Cancer r Rheumatoid Arthritis r Heart Problems/Stroke rDiabetes rHigh Blood Pressure
______
I certify to the best of my knowledge, the above information is complete and accurate. If the health plan information is not accurate, or if I am not eligible to receive a health care benefit through this provider, I understand that I am liable for all charges for services rendered and I agree to notify this doctor immediately whenever I have changes in my health condition or health plan coverage in the future.
Patient’s Signature: ______Date: ______
Pregnancy Release: This is to certify that to the best of my knowledge I am not pregnant and the above doctor and his/her associates have my permission to perform an x-ray evaluation. I have been advised that x-rays can be hazardous to an unborn child. Initial: ______
PATIENT HEALTH QUESTIONNAIRE
Patient Name ______Patient ID#______
If you have ever had a listed symptom in the past, please check that symptom in the PAST Column. KNOWLEDGE OF THESE CONDITIONS MAY INFLUENCE THE TYPE OT TREATMENT/THERAPY YOU RECEIVE
Past / Pres. / Condition / Past / Pres. / Condition / Past / Pres. / Conditionr / r / Neck Pain / r / r / Depression / r / r / Dermatitis/Eczema/Rash
r / r / Shoulder Pain (r Right r Left) / r / r / Angina / r / r / Heartburn/Indigestion
r / r / Pain in Upper Arm/Elbow (r R r L) / r / r / Heart Attack (date______) / r / r / Difficulty Swallowing
r / r / Hand Pain (r R r L) / r / r / Asthma / r / r / Constipation/Irregular Bowel Habits
r / r / Wrist Pain (r R r L) / r / r / Blood Disorder / r / r / Abdominal Pain
r / r / Upper Back Pain / r / r / Emphysema (Chronic Lung Disorder) / r / r / Loss of Bladder Control
r / r / Low Back Pain / r / r / Rheumatoid Arthritis / r / r / PMS
r / r / Pain in Upper Leg / Hip (r R r L) / r / r / Ulcer / r / r / Endometriosis
r / r / Pain in Lower Leg / Knee (r R r L) / r / r / Liver/Gallbladder Problems / r / r / Breast r soreness r lumps
r / r / Pain in Ankle or Foot (r R r L) / r / r / Kidney Stones / r / r / Rapid Heart Beat
r / r / Jaw Pain / r / r / Hepatitis / r / r / Irritable Colon
r / r / Swelling, Stiffness of Joint(s) / r / r / Bladder Infection / r / r / Colitis
r / r / Convulsions / r / r / Kidney Disorder (name ______) / r / r / Loss of Appetite
r / r / Headache / r / r / General Fatigue / r / r / Excessive Thirst
r / r / Muscular Incoordination / r / r / Chronic Sinusitis / r / r / Chest Pains
r / r / Tinnitus (Ear Noises/Ringing) / r / r / Chronic Cough / YES / NO
r / r / Do you have a permanent Disability Rating?
HEALTH HABITS Location:______
rY / rN / Do you smoke? ______Packs/Day / YES / NO / Date Rating Received ______/______/____rY / rN / Drink alcohol?______Drinks/Month / r / r / Do you exercise regularly? / Rating Percentage ______%
rY / rN / Coffee/Soda? ______Drinks/Day / What type? Cardio___ Flexibility___ Resistance__
Frequency? ______per week
Do you wear ______Heel Lifts ______Arch Supports
EXPERIENCE WITH CHIROPRACTIC / Yes / No
Have you ever been adjusted by a Chiropractor before? / r / r
Reason for those visits: ______
Previous Chiropractor’s Name: ______
Approximate date of last visit: ______
PLEASE TELL US ABOUT ANY STRESS RELATED TO YOUR BIRTH
Yes / No
1) Drugs/medicine/alcohol in pregnancy / r / r / ______
2) Labor chemically induced / r / r / ______
3) Forceps/Vacuum Extraction/C-Section / r / r / ______
4) Premature delivery / r / r / ______
5) Vaccination / r / r / ______
6) Falls in first year of life / r / r / ______
7) Any health related problems / r / r / ______
PLEASE TELL US ABOUT ANY STRESS RELATED TO YOUR CHILDHOOD
1) Any falls or injuries / r / r / ______
2) Allergy/Asthma or respiratory / r / r / ______
3) Ear Infections / r / r / ______
4) Digestive problems / r / r / ______
5) Hyperactivity / r / r / ______
7) Any health related problems / r / r / ______
PLEASE TELL US ABOUT ANY STRESS RELATED TO THE PRESENT
1) Auto Injuries / r / r / ______
2) Work Injuries / r / r / ______
3) Sports Injuries / r / r / ______
4) Work Stress / r / r / ______
5) Family/Home Stress / r / r / ______
6) Prescription Drug use / r / r / ______
7) Hospitalizations/Surgeries / r / r / ______
8) Major illnesses / r / r / ______
9) Recurring illness / r / r / ______
10) Limited exercises / r / r / ______
11) Poor nutrition / r / r / ______
GOALS FOR MY CARE
People see Chiropractors for a variety of reasons. Some go for a relief of pain, some to correct the cause of pain and others for correction of whatever is malfunctioning in their bodies. Your doctor will weigh your needs and desires when recommending your treatment program. Please check the type of care desired so that we may be guided by your wishes whenever possible.
r / I want the Doctor to select the type of care appropriate for my conditionr / Comprehensive Care – Caring for the whole body, not just the symptomatic area. This works on achieving the highest state in your body
r / Chiropractic Care – correcting and relieving the cause of the problem as well as the symptoms
r / Relief Care – Symptomatic relief of pain or discomfort