Merritt Chiropractic
Personal Information
How did you hear about us? ______
Name Last: ______Middle:______First: ______
DOB: ___/____/____ Sex: _____ SS# ______-______-______
Street Address: ______Email: ______
City/State/Zip: ______Best Phone: ______
Emergency Contact:______Phone Number : ______
What is your primary goal of care? ______
If you have no complaints skip to Personal History Section
What is your primary concern? ______
Describe the pain:
Sharp Shooting Aching Dull
Numb Throbbing Pins and Needles Burning
Does it move to other places? Y N
On a scale of 1 to 10 how much is it bothering you?
1 2 3 4 5 6 7 8 9 10
How long ago did it start? ______
Does anything make it better? What? ______
Does anything make it worse? What? ______
Please mark on the diagram where you experience the complaint and any addition complaints as well, if any.
Do you have something else you’d like us to address?
______
Describe the pain:
Sharp Shooting Aching Dull Numb Throbbing Pins and Needles Burning
On a scale of 1 to 10 how much is it bothering you?
1 2 3 4 5 6 7 8 9 10
How long ago did it start? ______Does it move to other places? Y N
Is there anything that makes it better? What? ______Worse? What? ______
Anything else bothering you?
Personal Health History
Has something like this happened before? ______
Are any of your complaints a results of a vehicle collision or work accident? Y N
Write P for Past conditions, C for Current and N for Never
Allergies / Diabetes / High Blood Pressure / StrokeAsthma / Unexplained weight change / Insomnia / Smoking
Cancer (type) / Frequent colds / Major Traumas / Surgeries
Clots / Heart Disease / Obesity / Vehicle Collisions
Females: Are you currently pregnant? Y N On birth control medication? Y N
Do you have biological children? Y N How Many? ______C-Sections? Y N
Family History
Do you have a family history of:
The same complaints you are in here for? Y N
Cancer? Y N Diabetes? Y N Heart Disease` Y N High Blood Pressure Y N
Lifestyle
How many hours of sleep do you get a night? _____ Is it restful? Y N
How is your stress level on a scale of 1-10? _____ Do you feel you cope with stress well? Y N
How many oz of non diuretic liquid do you drink a day? ______
How many Vegetable serving per day? ______
Is your diet generally healthy? Y N Are you happy with your diet? Y N
Do you do some kind of physical activity everyday? Y N How much? ______
Do you drink Alcohol? Y N If so, how much? ______
List any medications/Supplements?
______
To the best of my knowledge, the above information is true and correct
______
Signature Date