Download Welcome to our office! You`re going to love it here! Today`s Date

Welcome to our office!
You’re going to love it here!
_________________________________________________________________________________________________________________
Today’s Date: ___ /___ /________
We love our patients. Who may we thank for referring you here? ______________________________________________________
Patient Information:
First Name: _____________________________
Middle Name: ____________________________ Last Name: ________________________
SSN: _____________________________________
Date of Birth: ____________________________
Sex:  Male
 Female
Marital Status: Single Married Divorced Widowed Spouse’s Name: _____________________ # of Children: _______
Home #: __________________________________
Cell #: _____________________________________ Work #: ____________________________
Address: _____________________________________________________________________________________________________________________________
City: _______________________________________ State: ______________________________________ Zip Code: ___________________________
Emergency Contact: _____________________ Emergency Relation: _____________________ Emergency Phone: ________________
E-mail: _____________________________________________________________________________________
Employer Information:
Employed: Full Time Part Time Retired Student Unemployed
Employer Name:____________________________________________________________________________________________________________________
Employer Address:_________________________________________________________________________________________________________________
Employer City:____________________________ Employer State:___________________________ Employer Zip:______________________
Occupation:_______________________________ Work Supervisor:_________________________ Supervisor #:_______________________
Work Duties:________________________________________________________________________________________________________________________
Insurance Information
Insurance
Worker’s Comp
Self-Pay (Cash)
Personal Injury/Auto
 Other (explain):_____________________
Primary Name:_______________________
Primary Phone:_____________________________ Primary DOB:______________________
Address:_____________________________________________________________________________________________________________________________
City:________________________________________ State:________________________________________ Zip Code:___________________________
ID/Policy #:_______________________________ Group #:____________________________________
Secondary Name:_________________________ Secondary Phone:__________________________ Secondary DOB:____________________
Address:_____________________________________________________________________________________________________________________________
City:________________________________________ State:________________________________________ Zip Code:____________________________
ID/Policy #:_______________________________ Group #:____________________________________
Claim #:____________________________________ Claim Contact:______________________________ Claim Phone:_______________________
Attorney Name:_____________________________________________________________________________ Attorney Phone:____________________
----------------------------------------------------------------------------------------------------------------------------- -------------------------Who is responsible for payment? Self / Other – (Relationship) ______________________________________
Other than self:
Full Name: _________________________________________________ Phone: ____________________________________
Address: __________________________________________ City: ________________________ State: _______________ Zip: _____________
It is usual and customary to pay for services as rendered unless otherwise arranged.
Patient #: ____________________
Love Chiropractic LLC
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History of Current Condition
Describe Major Complaint: ________________________________________________________________________________________________________
Began When?: ___/___/______ Describe how this began: _________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Grade Intensity/Severity of Complaint: (Circle) None / Mild / Moderate / Severe / Very Severe
Quality of the complaint/pain: Sharp / Stabbing / Burning / Achy / Dull / Stiff & Sore / Other: ________________________
How frequent is the complaint present? (Circle) Off & On / Constant
Does this complaint radiate/shoot to any areas of your body? No / Yes (Describe) _________________________________________
Head- Base of Skull / Forehead / Sides-Temple
Arm- Across Shoulder / Elbow / Hand-Fingers
R / L / Both
R / L / Both
Leg- Hip / Thigh-Knee / Calf / Foot-Toes R / L / Both
Other Area: _____________________________________________________________
Does anything make the complaint better? Ice / Heat / Rest / Movement / Stretching / OTC / Other: ________________
Does anything make the complaint worse? Sit / Stand / Walk / Lying / Sleep / Overuse / Other: _____________________
Which daily activities are being affected by this condition? (Describe) ___________________________________________________
For this CURRENT condition, have you:
- Received any other treatment? None / DC / MD / PT / Massage / ER / Other: __________ Where? _____________
- Had any previous Surgery or Interventions in this area? (Describe) ____________________________________________
- Taken any Medications? OTC / Prescriptions ________________________________________________________________________
- Had any diagnostic testing? X-Ray / MRI / CT / Other: __________________ When & Where? ________________________
Please describe any secondary complaints: _____________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Please indicate where your pain is:
Patient #: _____________________
Love Chiropractic LLC
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Health History: (Please use the reverse side of this page if additional space is needed)
Medications: (Please list the medication and the dosage, include vitamins and supplements)
Medications
Dosage
Medications
Dosage
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Please list Allergies and your Reaction to the Allergy:
Allergy:_____________________________________________________
Allergy:_____________________________________________________
Allergy:_____________________________________________________
Allergy:_____________________________________________________
Reaction:___________________________________________________
Reaction:___________________________________________________
Reaction:___________________________________________________
Reaction:___________________________________________________
Past Surgical History: (Include date, surgeon’s name, type of surgery and any complications)
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Past Hospitalizations: (Date, complications, and cause of hospitalizations)
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Major Hospitalizations: None ____________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Family Health History: (Please mark N/A if not relevant.)
List relevant major health problems of immediate relatives:
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Deaths in immediate family: (Cause and at what age?)
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Social & Occupational History:
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Level of Education Completed: _______________________________
High School / Some College / College Graduate / Post Graduate / Other
Lifestyle: (Hobbies, Rec. Activities, Exercise, Diet, Work, Vitamins)
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Habits:
Cigarettes – (#/day) _______________________________________________________________________________________________________________
Alcohol – (amount/day) ___________________________________________________________________________________________________________
Coffee / Tea – (cups/day) __________________________________________________________________________________________________________
Rec. Drug (List) ____________________________________________________________________________________________________________________
Patient #: ___________________________
Love Chiropractic LLC
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Review of Systems:
Are you currently experiencing any of these symptoms? (Check all that apply)
Many of the following conditions respond to Chiropractic Care!
General: (constitutional)
 Recent Weight Change
 Fever
 Fatigue
 None in this Category
Musculoskeletal:
 Low Back Pain
 Mid Back Pain
 Neck Pain
 Arm Problems___________________
 Leg Problems ___________________
 Painful Joints
 Stiff/Swollen Joints
 Sore/Weak Muscles or Joints
 Muscle Spasms/Cramps
 Broken Bones: __________________
 Other: ___________________________
 None in this Category
Neurological:
 Numbness or Tingling Sensations
 Loss of Feeling
 Dizziness or Light Headed
 Frequent or Recurrent Headaches
 Convulsions or Seizures
 Tremors
 Stroke
 Have you ever had a head injury?
 Ever been in an auto accident?
 Other: _______________________________
 None in this Category
Mind/Stress:
 Nervousness
 Depression
 Sleep Problems
 Memory Loss or Confusion
 Other: _______________________________
 None in this Category
Genitourinary:
 Sexual Difficulty
 Kidney Stones
 Burning/Painful Urination
 Change in Force/Strain with Urination
 Frequent Urination
 Blood in Urine
 Incontinence or Bed Wetting
 Other: ________________________________
 None in this Category
Gastrointestinal:
 Loss of Appetite
 Blood in Stool
 Change in Bowel Movements
 Painful Bowel Movements
 Nausea or Vomiting
 Abdominal Pain
 Frequent Diarrhea
 Constipation
 Other: _______________________
 None in this Category
Cardiovascular & Heart:
 Chest Pains
 Rapid or Heartbeat Changes
 Blood Pressure Problems
 Swelling of Hands, Ankles, or Feet
 Heart Problems
 Other: _______________________________
 None in this Category
Respiratory:
 Difficulty Breathing
 Persistent Cough
 Coughing Blood
 Asthma or Wheezing
 Lung Problems
 Other: _______________________________
 None in this Category
Eyes & Vision:
 Wear Contacts/Glasses
 Blurred or Double Vision
 Glaucoma
 Eye Disease or Injury
 Other: _______________________________
 None in this Category
Ears, Nose, & Throat:
 Bleeding Gums / Mouth Sores
 Irregular Bad Breath or Bad Taste
 Dental Problems
 Swollen Throat or Voice Change
 Swollen Glands in Neck
 Ringing in the Ears
 Ear-Ache/Ringing/Drainage
 Sinus / Allergy Problems
 Nose Bleeds
 Hearing Loss
 Other: ________________________________
 None in this Category
Endocrine, Hematologic, & Lymphatic:
 Thyroid Problems
 Diabetes
 Excessive Thirst or Urination
 Cold Extremities
 Heat or Cold Intolerance
 Change in Hat or Glove Size
 Dry Skin
 Glandular or Hormone Problems
 Swollen Glands
 Anemia
 Easily Bruise or Bleed
 Phlebitis
 Transfusion
 Immune System Disorder
 Other: _______________________________
 None in this Category
Skin & Breasts:
 Rash or Itching
 Changes in Skin Color
 Change in Hair or Nails
 Non-healing Sores
 Change of Appearance of a Mole
 Breast Pain
 Breast Lump
 Breast Discharge
 Other: ______________________________
 None in this Category
Women Only:
Are You Pregnant?
Yes – Due Date ___/___/_____
No – Last Menstrual Period
___/___/_____
 Infertility
 Painful or Irregular Periods
 Vaginal Discharge
 Other: _______________________________
 None in this Category
Pregnancies with Outcome & Date:
__________________________________________
__________________________________________
__________________________________________
__________________________________________
Anything else not mentioned previously that the doctor should be aware of: _______________________________________________________________
_______________________________________________________________________________________________________________________________________________________
I have read the above information and certify it to be true and correct to the best of my knowledge, & hereby authorize this office to provide me with
chiropractic care, diagnostic testing, and/or therapeutic services, in accordance with this state’s statues.
Patient or Guardian Signature: ________________________________________________________________
Treating Doctor Signature: ____________________________________________________________________
Date: ___________________________________
Date: ___________________________________
Patient #: ________________________
Love Chiropractic LLC
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