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PATIENT INFORMATION FORM
____________________________
TODAY’S DATE:
NAME:
☐ MALE
☐FEMALE
ADDRESS:
CITY:
DATE OF BIRTH:
☐MARRIED
☐DIVORCED
AGE:
☐SINGLE
☐SEPARATED
STATE:
HOME PHONE:
CELL:
SOCIAL SECURITY #:
DRIVER’S LICENSE:
SPOUSE’S NAME:
AGES OF CHILDREN:
EMPLOYER/BUSINESS NAME:
BUSINESS ADDRESS:
BUSINESS PHONE:
TYPE OF WORK:
☐WIDOWED
☐________
ZIP:
FAX:
STATE:
EMAIL ADDRESS:
OCCUPATION/JOB TITLE:
HOW DID YOU HEAR ABOUT US?
EMERGENCY CONTACT:
PHONE #:
INSURANCE
ADDRESS:
RELATIONSHIP:
WHO IS RESPONSIBLE
FOR YOUR BILL?
☐SELF
☐WORKER’S COMP
☐AUTO INSURANCE
MEDICARE
☐MEDICAID
☐OTHER (BE SPECIFIC):
PERSONAL HEALTH INSURANCE CARRIER:
HEALTH ID CARD #:
INSURED PERSON’S NAME:
PRIMARY CARE PHYSICIAN:
INSURED PERSON’S SOCIAL SECURITY #:
PHARMACY:
CURRENT HEALTH CONDITION
CHIEF COMPLAINT: (WHY ARE YOU HERE TODAY?)
PLEASE CIRCLE AREAS OF DISCOMFORT
BODY AREA INVOLVED:
☐CERVICAL (NECK)
☐SPINE (MID-BACK), RIBS, PELVIS (LOW BACK)
CONDITION:
☐NEW
☐RECURRING
MECHANISM OF ONSET:
☐AUTO
☐FALL
☐OVER EXERTION
☐WORK
☐LIFTING
☐REPETITIVE MOTION
SYMPTOMS:
☐PAIN
☐STIFFNESS
☐NUMBNESS
☐WEAKNESS
LOCATION:
☐LEFT
☐BILATERAL
☐RIGHT
QUALITY:
☐BURNING
☐DIFFUSE
☐DULL/ACHING
☐LOCALIZED
☐SHARP
☐SHOOTING
☐UPPER EXTREMITY (ARMS, WRIST, HANDS)
☐LOWER EXTREMITY (LEGS, FEET, TOES)
☐EXACERBATION
☐CHRONIC
☐UNKNOWN
☐SLIP OR FALL
☐OTHER
☐SLEPT WRONG
☐NO INJURY
☐STABBING
☐THROBBING
☐TIGHTNESS
☐TINGLING
☐RADIATING
☐OTHER
ON A SCALE OF 0-10, (10 BEING THE WORST) RATE YOUR SYMPTOMS (RESTING):
0
1
2
3
4
5
6
7
8
9
10
ON A SCALE OF 0-10, (10 BEING THE WORST) RATE YOUR SYMPTOMS (WITH ACTIVITY):
0
1
2
3
4
5
6
7
8
9
10
DURATION: SYMPTOM(S) STARTED:
SYMPTOM(S) WORSENED:
SYMPTOM(S) LAST OCCURRED:
SYMPTOM(S) LAST EPISODE:
INJURY OCCURRED:
ACCIDENT OCCURRED:
TIMING WORSE IN THE:
☐MORNING
ASSOCIATED SIGNS
& SYMPTOMS:
☐BLURRED
☐VISION
☐DEPRESSION
☐DIZZINESS
☐ DULL
☐ SHARP
QUALITY OF
HEADACHES:
OTHER ASSOC. SIGNS
& SYMPTOMS:
MODIFYING FACTORS –
SYMPTOMS BETTER
WITH:
SINCE CONDITION
BEGAN, HAS ANYTHING
PERMANENTLY HELPED
YOU?
HAS ANYTHING THAT
YOU HAVE DONE, THUS
FAR, FIXED YOUR
PROBLEM
☐ACHES
☐COLD LIMB
☐DIZZINESS
☐FATIGUE
☐ACTIVITY
☐BENDING
☐AFTERNOON
☐NIGHT
☐W/ACTIVITY
☐HEADACHES
☐IRRITABILITY/MOOD SWING
☐LOCALIZED TINGLING
☐THROBBING
☐STABBING
☐COLD
☐HEAT
☐AURA
☐NO AURA
☐FEVER
☐HEARTBURN
☐MUSCLE SPASM
☐NAUSEA
☐MASSAGE
☒MOVEMENT
☐CONSTANT
☐NAUSEA
☐RADIATING
☐RINGING IN EARS
☐RADIATION:
☐WEAKNESS:
☐NUMBNESS
☐PALE BLUISH SKIN
☐PANIC
☐PINS & NEEDLES
☐OTC MEDS
☐REST
☐RX MEDS
☐STRETCHING
☐LEFT
☐LEFT
☐RUNNY NOSE
☐STIFFNESS
☐SWEATING
☐SWELLING
☐SITTING
☐STANDING
☐
INTERMITTENT
☐SLEEP
☐DISTURBANCE
☐STIFFNESS
☐RIGHT
☐RIGHT
☐BILATERAL
☐BILATERAL
☐TINGLING
☐VOMITING
☐WEAKNESS
☐TWISTING
☐WALKING
☐NOTHING
HELPS
☐YES
☐NO
☐YES
☐NO
EMPLOYMENT
OCCUPATION:
JOB CLASSIFICATION:
WORK (HRS/DAY):
☐SITTING
☐LIGHT
☐MODERATE
☐SITTING
☐STANDING
REPETITIVE ACTIVITIES: (HRS/DAY)
☐COMPUTER
☐PHONE
HOW DOES THIS CONDITION EFFECT JOB PERFORMANCE:
WORK ACTIVITY POSTURES: (HRS/DAY)
LIFTING
☐HEAVY
☐CONSTANT
☐FREQUENT
☐OCCASIONAL
FREQUENCY:
LIFTING
(66-100% DAY)
(33-65% DAY)
(0-32% DAY)
☐WALKING
☐PUSHING
☐KNEELING
☐TWISTING
☐CLIMBING
☐PULLING
☐REACHING
☐BENDING
☐MACHINERY
☐ASSEMBLY
☐HAND TOOLS
☐GRASPING
☐MILD PAINFUL (CAN DO)
☐SEVERE (UNABLE TO
PERFORM)
☐MODERATE PAINFUL (LIMITED)
☐OTHER (EXPLAIN)
DAILY ACTIVITIES: ON A SCALE OF 0-10, TO WHAT LEVEL ARE YOU EXPERIENCING SYMPTOMS
WHILE PERFORMING THESE ACTIVITIES
ACTIVITY
(CHECK APPLICABLE COLUMN)
BENDING:
0
NO EFFECT
1
2
3
4
5
6
7
8
9
10
UNABLE TO DO
CARE –INFIRM FAMILY:
CARRYING GROCERIES:
CHANGE POS.–SIT-STAND:
CLIMB STAIRS:
DRIVING:
EXTENDED COMPUTER USE:
FEEDING:
HOUSEHOLD CHORES:
KNEELING:
LIFT CHILDREN:
LIFTING:
PET CARE:
READING (CONCENTRATION):
SELF CARE:
SELF CARE–BATHING:
SELF CARE–DRESSING:
SELF CARE–SHAVING:
SEXUAL ACTIVITIES:
SLEEP:
STATIC SITTING:
STATIC STANDING:
WALKING:
YARD WORK:
BELOW IS A LIST OF DISEASES THAT MAY SEEM UNRELATED TO THE PURPOSE OF YOUR APPOINTMENT.
HOWEVER, THESE QUESTIONS MUST BE ANSWERED CAREFULLY AS THE PROBLEMS CAN AFFECT YOUR OVERALL COURSE OF CARE.
REVIEW OF SYMPTOMS – PLEASE FILL OUT ALL OF THE SECTIONS, EVEN IF “DENY”
CONSTITUTIONAL:
☐CHILLS
☐WEIGHT GAIN
☐FATIGUE
☐DAYTIME SOMNOLENCE
☐I DENY ANY CONST. ISSUE(S)
(DROWSINESS)
☐NIGHT SWEATS
☐WEIGHT LOSS
☐FEVER
EYE/VISION: ☐I DENY
ANY EYE/VISION ISSUE(S)
☐BLINDNESS
☐DOUBLE
VISION
☐EYE PAIN
☐PHOTOPHOBIA
EARS, NOSE, & THROAT:
☐I DENY ANY E/N/T
ISSUE(S)
☐BLEEDING
☐DISCHARGE
☐DIZZINESS
☐SNORING
RESPIRATION:
☐I DENY ANY
RESPIRATORY ISSUE(S)
CARDIOVASCULAR:
☐I DENY ANY CARDIO.
ISSUE(S)
☐ASTHMA
☐FAINTING
☐HEADACHES
☐LOSS OF SMELL
☐SORE THROATS
(FREQUENT)
☐COUGHING UP
BLOOD
GASTROINTESTINAL:
☐I DENY ANY GI ISSUE(S)
☐ABDOMINAL PAIN
☐BELCHING
☐BLACK, TARRY STOOLS
☐CONSTIPATION
☐ANGINA (CHEST PAIN
OR DISCOMFORT)
☐CHEST PAIN
☐CLAUDICATION (LEG
PAIN OR ACHINESS)
☐TEARING
☐BLURRED
VISION
☐FIELD CUTS
(VISUAL FIELD
DEFECT)
☐NASAL
CONGESTION
☐SINUS INFECTIONS
☐DENTAL IMPLANTS
☐SPUTUM
PRODUCTION
☐EAR DRAINAGE
☐EAR INFECTION(S)
☐HEARING LOSS
☐TINNITUS (RIGHT
IN EARS)
☐COUGH
☐HEART MURMUR
☐HEART PROBLEMS
☐ORTHOPNEA (DIFFICULTY BREATHING
WHILE LYING DOWN)
☐DIARRHEA
☐DIFFICULTY
SWALLOWING
☐HEARTBURN
☐HEMORRHOIDS
☐CATARACTS
☐GLAUCOMA
☐CHANGE IN
VISION
☐ITCHING
(AROUND EYES)
☐POST NASAL
DRIP
☐DIFFICULTY
SWALLOWING
☐EAR PAIN
☐SHORTNESS OF
BREATH
☐WEAR GLASSES
AND/OR
☐CONTACT
LENSES
☐HOARSENESS
☐RHINORRHEA
(RUNNY NOSE)
☐SINUS INFECTIONS
☐TMJ PROBLEMS
☐WHEEZING
☐PALPITATIONS (IRREGULAR
☐SWELLING OF LEGS
OR FORCEFUL BREATHING OF
☐ULCERS
THE HEART)
☐VARICOSE VEINS
☐PAROXYSMAL NOCTURNAL
DYSPNEA (WAKING AT NIGHT
WITH SHORTNESS OF BREATH)
☐INDIGESTION
☐ABNORMAL STOOL CALIBER
☐VOMITING
(QUALITY)
BLOOD
☐JAUNDICE
☐ABNORMAL STOOL COLOR
☐VOMITING
(YELLOWING OF SKIN)
☐NAUSEA
☐ABNORMAL STOOL CONSISTENCY
☐RECTAL BLEEDING
FEMALE: ☐I DENY ANY
FEMALE ISSUE(S)
MALE: ☐I DENY ANY
MALE ISSUE(S)
☐BIRTH CONTROL
THERAPY
☐BREAST LUMP/PAIN
☐BURNING URINATION
☐BURNING URINATION
☐PROSTATE PROBLEMS
☐CRAMPS
☐FREQUENT URINATION
☐HORMONE THERAPY
☐IRREGULAR MENSTRUATION
☐URINE RETENTION
☐VAGINAL BLEEDING
☐VAGINAL DISCHARGE
☐ERECTILE DYSFUNCTION
☐FREQUENT URINATION
☐URINATION RETENTION
☐HESITANCY/DRIBBLING
ENDOCRINE: ☐I DENY
ANY ENDOCRINE ISSUE(S)
☐COLD
INTOLERANCE
☐DIABETES
☐EXCESSIVE
APPETITE
☐EXCESSIVE
HUNGER
SKIN: ☐I DENY ANY SKIN
ISSUE(S)
☐CHANGES IN NAIL TEXTURE
☐CHANGES IN SKIN COLOR
NERVOUS SYSTEMS:
☐I DENY ANY NS ISSUE(S)
☐DIZZINESS
☐FACIAL
WEAKNESS
PSYCHOLOGICAL:
☐I DENY ANY
PSYCHOLOGICAL ISSUE(S)
☐ANHEDONIA
(INABILITY TO
EXPERIENCE JOY
OR ENJOY LIFE)
ALLERGY: ☐I DENY ANY
ALLERGY ISSUE(S)
☐ANAPHYLAXIS (HISTORY
OF SNEEZING)
HEMATOLOGY: ☐I DENY
ANY HEMATOLOGY
ISSUE(S)
☐ANEMIA
☐BLEEDING
☐EXCESSIVE THIRST
☐FREQUENT
URINATION
☐HAIR
GROWTH
☐HAIR LOSS
☐HEADACHES
☐LIMB
WEAKNESS
☐ANXIETY
☐APPETITE
CHANGES
☐HIVES
☐ITCHING
☐LOSS OF
CONSCIOUSNESS
☐LOSS OF MEMORY
☐BEHAVIORAL
CHANGE(S)
☐BIPOLAR DISORDER
☐FOOD INTOLERANCE
☐BLOOD CLOTTING
☐BLOOD TRANSFUSION(S)
☐GOITER
☐HAIR LOSS
☐PARESTHESIA
(NUMBNESS, PRICKLING,
OR TINGLING)
☐NUMBNESS
☐SEIZURES
☐HEAT
INTOLERANCE
☐UNUSUAL HAIR
GROWTH
☐RASH
☐HISTORY OF SKIN
DISORDERS
☐SLEEP
DISTURBANCE
☐STRESS
☐CONFUSION
☐CONVULSIONS
☐VOICE
CHANGES
☐SKIN LESIONS
/ULCERS
☐VARICOSITIES
☐STROKES
☐TREMORS
☐
UNSTEADINESS
OF GAIT
☐DEPRESSION
☐INSOMNIA
☐MEMORY
LOSS
☐MOOD
CHANGES
☐ITCHING
☐NASAL CONGESTION
☐SNEEZING
☐BRUISES EASILY
☐FATIGUE
☐LYMPH NODE SWELLING
PAST HEALTH HISTORY – PLEASE FILL OUT CAREFULLY AS THESE PROBLEMS CAN AFFECT YOUR OVERALL COURSE OF CARE.
CHILDHOOD ILLNESS:
☐I DENY ANY
CHILDHOOD ILLNESS(ES)
ADULT ILLNESS:☐I DENY
ANY ADULT ILLNESS(ES)
SURGERIES:☐I DENY ANY
SURGERY (IES)
OB/GYN:☐I DENY ANY
OB/GYN ISSUES
INJURIES:☐I DENY ANY
INJURY (IES)
IMMUNIZATIONS:
☐I DENY ANY
IMMUNIZATION(S)
NON-DRUG ALLERGIES:
☐I DENY ANY NON-DRUG
ALLERGIES
☐ADD
☐BED WETTING
☐DIABETES
☐FOOD
☐MEASLES
☐SEIZURE DISORDER
☐ALLERGIES/HAYFEVER
☐CEREBRAL
☐EAR INFECTIONS ALLERGIES
☐MUMPS
☐SICKLE CELL ANEMIA
☐HEADACHES
PALSY
☐ASTHMA
☐FETAL DRUG
☐RASH
☐SPINA BIFIDA
☐CHICKEN POX
☐HEPATITIS
☐ATOPIC DERMATITIS
☐EXPOSURE
☐SCOLIOSIS
☐OTHER (PLEASE
☐DEPRESSION
☐HIV
(ECZEMA)
DESCRIBE)
☐ALZHEIMERS
☐CVA (STROKE)
☐FIBROMYALGIA
☐LUPUS ERYTHEMA
☐SEIZURE DISORDER
(DISCOID)
☐ANEMIA
☐CYSTIC KIDNEY DISEASE
☐HEART DISEASE
☐SHINGLES
☐LUPUS ERYTHEMA
☐ARTHRITIS
☐DEPRESSION
☐HEPATITIS
☐STD’S (UNSPECIFIED)
(SYSTEMIC)
☐ASTHMA
☐DIABETES (INSULIN)
☐HIV
☐SUICIDE ATTEMPT(S)
☐MULTIPLE SCLEROSIS
☐CANCER
☐DIABETES (NON INSULIN)
☐HYPERTENSION
☐THYROID PROBLEMS
☐PARKINSON’S DISEASE
☐CHICKEN BOX
☐EAR INFECTIONS
☐INFLUENZA
☐VERTIGO
☐PLEURISY
(FREQUENT)
PNEUMONIA
☐CHRON’S/COLITIS
☐PAST HISTORY OF
☐PNEUMONIA
☐EMPHYSEMA
☐LIVER DISEASE
SIMILAR SYMPTOMS TO
☐CRPS (RSD)
☐PSYCHIATRIC PROBLEMS YOUR CURRENT
☐EYE PROBLEMS
☐LUNG DISEASE
CONDITION
☐SCOLIOSIS
☐OTHER ____________________________________________________________________________________________________
☐ANGIOPLASTY
☐CORONARY ARTERY
☐HEMORRHOIDECTOMY
☐LAMINECTOMY
BYPASS
☐APPENDECTOMY
☐HERNIA REPAIR
☐MASTECTOMY
☐COSMETIC
☐CAESAREAN SECTION
☐HYSTERECTOMY
☐PACEMAKER
☐D & C
INSERTION
☐CARDIAC
☐JOINT RECONSTRUCTION
☐DENTAL SURGERY
☐ROTATOR CUFF
CATHETERIZATION
☐JOINT REPLACEMENT
☐CARPAL TUNNEL
☐GALL BLADDER
☐SPINAL FUSION
REPAIR
MENSTRUAL HISTORY:
☐I HAVE NEVER BEEN PREGNANT
☐MY MENSES IS REGULAR
☐I HAVE BEEN PREGNANT IN THE PAST
☐MY MENSES IS IRREGULAR
AGE OF ONSET _____
☐I AM CURRENTLY PREGNANT
☐I AM CURRENTLY IN MENOPAUSE
☐BACK INJURY
☐BROKEN BONES
☐SEVERE FALL
☐DTAP (DIPTHERIA,
TETANUS &
PERTUSSIS)
☐ANIMALS
☐TONSILLECTOMY
☐OTHER
DATE OF LAST
MENSES
___/___/___
☐FRACTURE
☐INDUSTRIAL ACCIDENT
☐MOTOR VEHICLE ACCIDENT
☐DISABILITY
☐JOINT INJURY
☐MILD/MODERATE SOFT TISSUE INJURY
☐HEAD INJURY
☐SEVERE LACERATION
☐SEVERE SOFT TISSUE INJURY
☐FLU
☐HEPATITIS C
☐MMR (MEASLES, MUMPS,
☐SMALL POX
☐WHOPPING
& RUBELLA)
COUGH
☐HEPATITIS A
☐INFLUENZA
☐TB
(PERTUSSIS)
☐PNEUMOCOCCAL
☐HEPATITIS B
☐IPV (POLIO)
☐VARIVAX (CHICKEN
☐PPD (MANTOUX TEST-TB)
POX)
☐DAIRY
☐EGGS
☐FOOD COLORING
☐MOLD
☐POLLEN
PREVIOUS TREATMENT
☐YES IF YES, WHO? (NAME)
☐NO
☐YES IF YES, WHO? (NAME)
☐NO
PREVIOUS CHIROPRACTIC CARE?
HAVE YOU SEEN OTHER
DOCTORS FOR THIS
CONDITION?
WERE YOU SASTIFIED WITH THE
RESULTS OF YOUR TREATMENT?
ARE YOU CURRENTLY TAKING
ANY PRESCRIPTION
MEDICATIONS?
DO YOU WEAR ANY OF THE
FOLLOWING?
☐YES EXPLAIN:
☐NO
☐YES IF YES, PLEASE MARK
OR LIST (BE SPECIFIC)
☐NO
☐HEAL LIFTS
☐INNER SOLES
LOCATION OF OFFICE:
☐ALLERGY MEDICATION
☐ANTI-DEPRESSANTS
___ MOTHER
___ PATERNAL GRANDFATHER
NAME
☐BLOOD
☐MUSCLE
☐PAIN KILLERS
PRESSURE MEDS.
RELAXERS
☐OTHER (PLEASE
☐INSULIN
☐NERVE PILLS
SPECIFY)
PLEASE LIST ANY OTHER CONDITIONS YOU FEEL WE SHOULD KNOW
ABOUT – EVEN IF UNRELATED
☐ARCH SUPPORTS
☐ORTHOTICS
FAMILY HISTORY – ENTER INITIALS BELOW:
___ GENERAL
FAMILY
___ FATHER
___ PATERNAL GRANDMOTHER
___ MATERNAL GRANDFATHER
TYPE OF TREATMENT:
A = ALIVE
D = DECEASED
___ MATERNAL GRANDMOTHER
___ SON(S)
RELATION
___ DAUGHTER(S)
___ BROTHER(S)
___ SISTER(S)
PAST & PRESENT HEALTH PROBLEMS
SOCIAL HISTORY
ALCOHOL:
DRUGS:
OZ.’S # GLASSES
☐NEVER
☐SOCIAL
☐BEER
CONSUMPTION ☐LIQOUR
☐DAILY
ONLY
☐WEEKLY
☐WINE
☐MONTHLY
☐ DENY ANY ILLEGAL DRUG USE
☐ HAVE NOT USED DRUGS SINCE
_____
☐ DENY USE OF IV DRUGS
☐ HAVE USED DRUGS FOR _____
☐HIGH FAT
☐HIGH FIBER
☐HIGH PROTEIN
☐HIGH SALT
☐ DENY TOBACCO USE
☐ LIVE W/A SMOKER
☐ QUIT SMOKING
DIET:
MARK ALL THAT
APPLY
TOBACCO:
☐ LOW CALORIE
☐ LOW CARB
☐ LOW SUGAR
# PER:
___
☐ DAY
☐ WEEK
☐ MONTH
☐ LOW FIBER
☐ LOW SALT
☐ # CHEW
____
PLEAE READ CAREFULLY AND SIGN BELOW
I understand and agree that health and accident insurance policies are an agreement between an insurance carrier and myself. Furthermore, I understand that
chiropractic clinic will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be
paid directly to chiropractic clinic will be credited to my account upon receipt. However I clearly understand and agree that all services rendered me are charged
directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care or treatment, any fees for professional
services rendered me will be immediately due and payable. I agree that I am responsible for all bills incurred at this office. I hereby authorize the Doctor to treat my
condition as he or she deems appropriate through the use of Chiropractic Health Care, and I give authority for these procedures to be performed.
GUARDIAN OR SPOUSE’S SIGNATURE OF AUTHORIZING CARE:
DATE:
(SIGNATURE INDICATES CONSENT TO TREAT)
PATIENT (PRINT NAME):
PATIENT’S SIGNATURE:
DATE: