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Date:____________________________________________ Social Security No.:__________________________________

Name:___________________________________________ Address:___________________________________________

City:____________________________________________ State:_________Zip:_________________________________

Home Phone:_____________________Cell Phone:_____________________Business Phone:_______________________

E- Mail Address:_____________________________________________________________________________________

Birthdate: ___________________________Age:___________Gender: M F TG Other

Business/Employer:__________________________________ Type of Work:_____________________________________

Check One: ( ) Single ( ) Coupled ( ) Widowed No. Of Children:_____________________________

Name of Emergency Contact:________________________________Phone No.:__________________________________

Referred To This Office By:____________________________________________________________________________

Who Is Responsible For Your Bill? ( ) Self ( ) Spouse/Partner ( ) Workers Comp.( ) Auto Insurance ( ) Personal Health Insurance ( ) Other Party_________________________________________

_________________

Purpose Of This Appointment: __________________________________________________________________________

Other Doctors Seen For This Condition: ___________________________________________________________________

When Did This Condition Begin? ________________________________________________________________________

If Disabled From Work, Please Give Dates: ________________________________________________________________

( ) Job Related ( ) Auto Related

Current Medications: ( ) Pain Killers/Muscle Relaxers:___________________________________________________

( ) Nerve Pills:____________________________________ ( ) Blood Pressure Meds.:___________________________

( ) Insulin ( ) Other:______________________________________________________________________________

Major Accident or Falls:_______________________________________________________________________________

Broken Bones:_______________________________________________________________________________________

Major Surgery/Operations:______________________________________________________________________________

( ) Appendectomy ( ) Tonsillectomy ( ) Gall Bladder ( ) Hernia ( ) Other:_____________________

Hospitalizations (other than above):______________________________________________________________________

Previous Chiropractic Care: ( ) None ( ) Yes Approx. Date of Last Visit:_______________________________

Name of Doctor:_____________________________________ Office Location:__________________________________________

Have you been treated for any health condition in the last year: ( ) No ( ) Yes

If yes, please explain:_____________________________________________________________________________________________

PERSONAL HISTORY

CURRENT HEALTH CONDITION

HEALTH HISTORY PART I

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Please Check Any Of The Following Which Apply To You

[ ] Anemia [ ] Rheumatic Fever [ ] Pneumonia [ ] Arthritis

[ ] Measles [ ] Typhoid Fever [ ] Pleurisy [ ] Skin Conditions[ ] Mumps [ ] Scarlet Fever [ ] Diabetes [ ] Epilepsy

[ ] Whooping Cough [ ] Polio [ ] Thyroid Disease [ ] Mental Disorder

[ ] Diphtheria [ ] Tuberculosis [ ] Heart Disease [ ] Venereal Infection

[ ] Chicken Pox [ ] Malaria [ ] HIV+/AIDS [ ] Substance Dependencies

[ ] Small Pox [ ] Meningitis [ ] Cancer Type _________

_____________________

_

[ ] Other: ______________

Please Check Any Of the Following Which Currently Apply To You (within the past 6 months).

GENERAL GASTROINTESTINAL FEMALES ONLY

[ ] Allergies [ ] Poor/Excessive Appetite [ ] Menstrual Irregularity

[ ] Loss of sleep [ ] Excessive Thirst [ ] Menstrual Cramping

[ ] Fever [ ] Frequent Nausea [ ] Vaginal Pain/Infection[ ] Headaches [ ] Vomiting [ ] Reproductive Problems

MUSCULOSKELETAL [ ] Diarrhea [ ] Genital Herpes[ ] Low Back Pain [ ] Constipation [ ] Breast Pain/Lumps

[ ] Pain Between Shoulders [ ] Hemorrhoids

[ ] Neck Pain [ ] Liver Problems Are You Pregnant?[ ] Arm Pain / Leg Pain [ ] Gallbladder Problems / Stones [ ] Yes ( ) No ( ) Maybe

[ ] Joint Pain / Swelling [ ] Weight Trouble When was your last Period?

[ ] Walking Problems [ ] Abdominal Cramps ______________________________

[ ] Difficulty Chewing/ [ ] Gas/Bloating After Meals

Clicking Jaw [ ] Heartburn FEMALES OVER 40

NERVOUS SYSTEM [ ] Black/Bloody Stools [ ] Menopause

[ ] Numbness [ ] Colitis Perimenopausal Symptoms

[ ] Paralysis CV / RESPIRATORY [ ] Hot Flashes[ ] Dizziness [ ] Chest Pain [ ] Night Sweats

[ ] Forgetfulness [ ] Shortness of Breath [ ] Vaginal Dryness

[ ] Confusion/Depression [ ] Blood Pressure Problems [ ] Mood Sings

[ ] Fainting [ ] Irregular Heartbeat [ ] Weight Gain

[ ] Convulsions [ ] Heart Problems [ ] Other Symptoms_________ [ ] Cold/Tingling Extremities [ ] Lung Problems/Congestion ______________________________URINARY SYSTEM [ ] Varicose Veins MALES ONLY

[ ] Kidney Infection [ ] Leg/Ankle Swelling [ ] Prostate Problems[ ] Kidney Stones EENT [ ] Reproductive Problems

[ ] Bladder Infection [ ] Vision Problems [ ] Sexual Dysfunction[ ] Bladder Problems [ ] Dental Problems [ ] Genital Herpes

[ ] Painful Urination [ ] Sore Throat [ ] Other Symptoms_______

[ ] Excessive Urination [ ] Ear Aches _____________________________

[ ] Discolored Urine [ ] Hearing Difficulties

HEALTH HISTORY PART II

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Please mark the location of your pain or discomfort on the images below. Use the symbols shown to

represent the types of pain.

D = DULL B =BURNING N = NUMBNESS

S = STABBING T = TINGLING (Pins & Needles) C = CRAMPING

On the scales below, please draw a vertical line representing the intensity of your pain or

discomfort.

Rate the pain you have right now: Rate your pain at its best during the past week

NO PAIN UNBEARABLE PAIN NO PAIN UNBEARABLE PAIN

|________________________________________| |_____________________________________|

Rate your pain on average during the past week: Rate your pain at its worst during the past week:

NO PAIN UNBEARABLE PAIN NO PAIN UNBEARABLE PAIN

|________________________________________| |_____________________________________|

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