Stamford Family Wellness Intake Form

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Personal History
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Age*
Gender Identity and Pronouns
What is your Gender? If other, please indicate your preferred pronoun*
Social Security Number
All submissions are kept private and confidential
Marital Status

MarriedSingleWidowedDivorcedSeparated
Business Employer
Type of Work
Name of Spouse
Name and Ages of Children
Name and Number of Emergency Contact.
Relationship to Emergency Contact
Who is Responsible for Your Bill, You and

SpouseWorkers CompAuto InsurancePersonal Health InsuranceOther
Personal Health Insurance Name, if you don't have insurance, type None
Health Card Number
Insured Person’s Name
Insured Date of Birth

MonthDayYear
Date
Current Unwanted Health Condition
Unwanted Health Conditions *
Other Doctors Seen Names and what type of practitioner
Type of Treatment
Results of Treatment
When Did This Condition Begin?*

MonthDayYear
Date
Has This Conditon Occured Before?*
Please Outline On The Diagram The Area of Your Discomfort.
Is Condition*

Job RelatedAuto AccidentHome InjuryFallOther
Date of Accident

MonthDayYear
Date
Are you currently taking any medication?*

YesNo
Do you have any medication allergies?*

YesNoNot Sure
Do you use or do you have history of using tobacco?*
Do you use or do you have history of using illegal drugs?*
Type a question
Have You Made A Report of Your Accident To Your Employer

YesNo
Drugs You Now Take

Nerve PillsPain Killers/Muscle RelaxersBlood Pressure MedicationInsulinOther
Do you Suffer From Any Other Condition Than That Which You Are Now Consulting With Us?
Past Health History
Please Describe Any Previous Surgeries.
Please Describe Any Major Accidents Or Falls
Please Tell Us About Any Hospitalizations Other Than Above
Have You Had Previous Chiropractic Care? When Was Your Last Visit
CHECK ANY OF THE FOLLOWING YOU HAVE HAD IN THE PAST 6 MONTHS:
MUSCULO-SKELETAL CODE

LOW BACK PAINPAIN BETWEEN SHOULERSNECK PAINARM PAINJOINT PAIN/STIFFNESSWALKING PROBLEMSJAW/CHEWING ISSUESGENERAL STIFFNESS
NERVOUS SYSTEM CODE

NERVOUSNUMBNESSPARALYSISDIZZINESSFORGETFULNESSCONFUSION/DEPRESSIONFAINTINGCONVULSIONSCOLD/TINGLING EXTREMITIESSTRESS
GENERAL CODE

FATIGUEALLERGIESLOSS OF SLEEPFEVERHEADACHES
GASTROINTESTINAL CODE

POOR/EXCESSIVE APPETITEEXCESSIVE THIRSTFREQUENT NAUSEAVOMITINGDIARRHEACONSTIPATIONHEMORRHOIDSLIVER PROBLEMSGALL BLADDER PROBLEMSWEIGHT TROUBLEABDOMINAL CRAMPINGGAS/BLOATING AFTER MEALSHEARTBURNBLACK/BLOODY STOOLCOLITIS
GENITO-URINARY CODE

BLADDER TROUBLEPAINFUL/EXCESSIVE URINATIONDISCOLORED URINE
C-V-R CODE

CHEST PAINSHORT BREATHBLOOD PRESSURE PROBLEMSIRREGULAR HEARTBEATHEART PROBLEMSLUNG PROBLEMS/ CONGESTIONVARICOSE VEINSANKLE SWELLINGSTROKE
EENT CODE

VISION PROBLEMSDENTAL PROBLEMSSORE THROATEAR ACHESHEARING DIFFICULTIESSTUFFED NOSE
MALE/FEMALE CODE

MENSTRUAL IRREGULARITYMENSTRUAL CRAMPSVAGINAL PAIN/INFECTIONBREAST PAIN/LUMPSPROSTATE/SEXUAL DISFUNCTIONOther
IF YOU MENSTRUATE

I AM PREGNANTI AM NOT PREGNANT
ARE YOUR MENSTRUAL PERIODS REGULAR

MonthDayYear
Date
ARE YOUR MENSTRUAL PERIODS REGULAR

YESNO
Check the conditions that apply to you or to any members of your immediate relatives:

AsthmaCancerCardiac diseaseDiabetesHypertensionPsychiatric disorderEpilepsyOther
Most patients that come to our office have one of two objectives in mind concerning thier health care. Some patients come for symptomatic relief of pain or discomfort (Relief Care). Others are interested in having the cause of the problem as well as the symptoms corrected and relieved (Corrective Care). Your doctor will weigh your needs and desires when recommending your treatment program.
What Kind Of Plan Makes The Most Sense To You For Your Health?*
Please Type your full name

First NameLast Name
Please enter today's date

MonthDayYear
Date
Signature*

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Personal History

Current Unwanted Health Condition

Past Health History