Personal Information

Personal Information
Name *

First Name Last Name
Birth Date *

Month Day Year
Date
Gender *

Female Male
Address *

Street Address

Street Address Line 2

City State

Zip Code Country
Occupation *
Employer Name *
Are you Current/Former Military and or a Student? *

Yes No
Youth Information
Is the patient under the age of 14? *

Yes No
Birth Height
Birth Weight
Current Height
Current Weight
Birth Type / Delivery Method
Mother's Name

First Name Last Name
Mother's Birth Date

Month Day Year
Date
Father's Name

First Name Last Name
Father's Birth Date

Month Day Year
Date
Pediatric/Family Medical Doctor (Include City & State of Operation Please)
Date of Last Visit

Month Day Year
Date
Reason for Last Visit
Who is Responsible for billing/payments? *
Mother's Social Security #
Father's Social Security #
Contact Information
Home Phone # *

Area Code Phone Number
Cell Phone #

Area Code Phone Number
Work Phone #

Area Code Phone Number
E-mail *
In Case of Emergency Contact *

First Name Last Name
Relation *
Emergency Contact # *

Area Code Phone Number
Family Information
Marital Status *
Name of Spouse
Anniversary Date

Month Day Year
Date
# of Children
Names of Children
Share Information
Would you like to give consent to anyone else to access your appointment and financial information? *

Yes No
Referral
Who may we thank for referring you to our office? *
i.e. Website/Facebook/Google/Patient (name)
Chiropractic History
Have you been adjusted by a chiropractor before? *

Yes No
Last Adjusted

Month Day Year
Date
Previous Chiropractor
Reason For Previous Visit
How did you respond?
Did your previous chiropractor take before and after x-rays? *

Yes No
The most common postural weakness is Forward Head Syndrome (head and neck starting to bend forward and progressively moving downward weakening your whole body). Even less severe forms of this posture can cause many adverse affects on your overall health. Have you ever been told or felt like you carry your head forward, noticed a rounding of your shoulders or a developing "hump" at the base of your neck? *

Yes No
Did you know posture determines your health? *

Yes No
Are you aware of any of your poor posture habits? *

Yes No
Please explain:
Are you aware of any poor posture habits in your spouse or children? *

Yes No
Please explain:
Health History
Please list any and all health conditions: *
Any past surgeries? *

Yes No
Please list all past surgeries:
Any major accidents in the past 5 years? *

Yes No
Please list all previous accidents including falls:
Have you had x-rays on your neck or spine in the past two years? *

Yes No
Have you had any pregnancies? *

Yes No
Are you currently pregnant? *

Yes No
Are you currently taking any medication? *

Yes No
Please list all Current Medications and the reason for their usage (including supplements):
Health Lifestyle
Do you exercise? *

Yes No
How Often?

1x Per Week 2x Per Week 3x Per Week 4x Per Week 5x Per Week
What activities?
Do you smoke? *

Yes No
How much and how often?
Do you drink alcohol? *

Yes No
How much and how often?
Do you drink coffee? *

Yes No
How much and how often?
Your Visit
What is your reason for seeking chiropractic care? *
Any bowel or bladder problems since this problem began? *

Yes No
Please explain:
Is the condition getting worse? *

Yes No
Does the condition interfere with the following:

Work Sleep Hobbies Daily Routine
Please explain:
Have you experienced this condition before? *

Yes No
Please explain:
Have you seen anyone for this? *

Yes No
Please explain who you saw, what they did and how you responded:
Is this a motor vehicle accident related injury? *

Yes No
When did the accident occur? *

Month Day Year
Date
Is this an organized sports related injury? *

Yes No
Chief Complaint
Character of complaint: What does the pain feel like? *
Are there associated symptoms that affect others areas of your body? *
When and how did the problem first occur? *
Rate the intensity of pain: *
How often does the pain occur? *
Indicate Locations Of Pain
Front Of Body

The Diagram can be used as a reference
Areas of the body affected on left side:

1: Head 2: Neck 3: Shoulder 4: Chest 5: Arm (Upper) 6: Elbow 7: Arm (Lower) 8: Wrist 9: Hand 10: Fingers 11: Abdominal 12: Groin 13: Leg (Upper) 14: Knee 15: Leg Lower) 16: Ankle 17: Foot 18: Toes
Areas of the body affected on right side:

1: Head 2: Neck 3: Shoulder 4: Chest 5: Arm (Upper) 6: Elbow 7: Arm (Lower) 8: Wrist 9: Hand 10: Fingers 11: Abdominal 12: Groin 13: Leg (Upper) 14: Knee 15: Leg Lower) 16: Ankle 17: Foot 18: Toes
Back Of Body

The Diagram can be used as a reference
Areas of the body affected on left side:

1: Head 2: Back (Upper) 3: Back (Mid) 4: Hip 5: Back (Lower) 6: Buttocks 7: Leg (Upper) 8: Behind Knee 9: Leg (Lower) 10: Heel
Areas of the body affected on right side:

1: Head 2: Back (Upper) 3: Back (Mid) 4: Hip 5: Back (Lower) 6: Buttocks 7: Leg (Upper) 8: Behind Knee 9: Leg (Lower) 10: Heel
Does the pain start in one place and radiate elsewhere? (radiation) *
How long does the onset of pain last for? (duration) *
Does anything intensify the pain? (aggravating factors) *
Does anything relieve the pain? (relieving factors) *
Family History
Have you or your family ever been diagnosed with the following:
Heart or Blood Disease? *

Yes No
High Blood Pressure? *

Yes No
Hardening of the arteries? *

Yes No
High Cholesterol? *

Yes No
Diabetes? *

Yes No
High or Low Blood Sugar? *

Yes No
Cancer? *

Yes No
Whiplash Injury/Neck Strain? *

Yes No
Bone Spurs of Neck Bones? *

Yes No
Visual or Hearing Disturbances? *

Yes No
Speech issues? *

Yes No
Eating/Swallowing Difficulty? *

Yes No
Digestive/Bowel Difficulty? *

Yes No
Dizziness/Vertigo or Imbalance? *

Yes No
Reproductive Disorders or Concerns? *

Yes No
Difficulty Sleeping/Apnea? *

Yes No
Fatigue? *

Yes No
Stress/Anxiety or other emotional concerns? *

Yes No
Learning Disabilities? *

Yes No
Loss of Consciousness? *

Yes No
Numbness or Loss of Sensation/Strength in fingers, face, arms or other? *

Yes No
Colic? *

Yes No
Asthma/Breathing Issues? *

Yes No
Skin Issues - eczema/rashes/acne? *

Yes No
Stroke? *

Yes No
Rocking, Shaking or Twitching? *

Yes No
Frequent Colds or Flus? *

Yes No
Headaches or Migraines? *

Yes No
Allergies? *

Yes No
Other? *

Yes No
Please explain:
Child History
Has your child ever experienced / exhibited the following: *

Headaches Orthopedic Problems Digestive Disorders Behavioral Problems Dizziness Neck Problems Poor Appetite ADD/ADHD Fainting Arm Problems Stomach Aches Ruptures/Hernia Seizures/Convulsions Leg Problems Reflux Muscle Pain Heart Trouble Joint Problem Constipation Growing Pains Chronic Earaches Backaches Diarrhea Allergies Sinus Trouble Poor Posture Hypertension Asthma Scoliosis Anemia Colds/Flu Walking Trouble Bed Wetting Colic Broken Bones Sleeping Problems Fell in baby walker Fell from bed or couch Fell from crib Fell off swing Fell off bicycle Fell from high chair Fell off slide Fell down stairs Fell from changing table Fell off monkey bars Fell off skateboard/skates Other Type of Fall None of the above
Allergies to
Other type of fall details

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Personal Information

Youth Information

Contact Information

Family Information

Share Information

Referral

Chiropractic History

Health History

Health Lifestyle

Your Visit

Chief Complaint

Indicate Locations Of Pain

Family History

Child History