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PATIENT INFORMATION NAME ____________________________________________________________________ DATE ___________________ ADDRESS____________________________________ CITY _______________________ STATE ______ZIP____________ SEX MALE FEMALE BIRTH DATE_____________ AGE ______ SINGLE MARRIED DIVORCED WIDOWED SPOUSES NAME ___________________ WHOM MAY WE THANK FOR REFERRING YOU? _________________________ *HEIGHT _______ WEIGHT ______ BLOOD PRESSURE _________ PREFERRED LANGUAGE ________________________ *RACE (CIRCLE ONE) UNSPECIFIED /AMERICAN INDIAN /ASIAN / BLACK OR AFRICAN AMERICAN / WHITE / OTHER RACE *ETHNICITY (CIRCLE ONE) UNSPECIFIED / HISPANIC OR LATINO / NOT HISPANIC OR LATINO *SMOKING STATUS (CIRCLE ONE) EVERY DAY SMOKER / OCCASIONAL SMOKER / FORMER SMOKER / NEVER SMOKED SOCIAL SECURITY # ________________ EMPLOYER _____________________ OCCUPATION______________________ CONTACT INFORMATION HOME PHONE ____________________ CELL PHONE _______________________ WORK PHONE ___________________ EMAIL ____________________________________________________________________________________________ EMERGENCY CONTACT NAME & # ______________________________________________________________________ ACCIDENT INFORMATION ARE YOUR COMPLAINTS DUE TO AN ACCIDENT? YES NO DATE __________ TYPE OF ACCIDENT AUTO WORK OTHER ATTORNEY NAME ______________________ PHONE _______________ PATIENT COMPLAINTS REASON FOR VISIT? _________________________________________________________________________________ WHEN DID THIS OCCUR? _____________________________________________________________________________ HOW DID THIS OCCUR? ______________________________________________________________________________ IS THIS GETTING? WORSE IMPROVING STAYING THE SAME SEVERITY(NONE)0..1..2..3..4..5..6..7..8..9..10 (SEVERE) TYPE OF PAIN SHARP ACHING/DULL SHOOTING NUMBNESS/TINGLING CONSTANT COMES & GOES LIMITS MY WORK SLEEP SITTING STANDING WALKING BENDING LYING DAILY ACTIVITY RECREATIONAL ACTIVITY OTHER _______________________ INDICATE WHERE YOU HAVE PAIN OR OTHER SYMPTOMS BELOW: FOR DR. USE ONLY: ONSET ________________________________ PAL/PROV _____________________________ ______________________________________ QUALITY ______________________________ RADIATING ____________________________ TIMING _______________________________ SITE __________________________________ 10025 W. GREENFIELD AVE WEST ALLIS, WI 53214 CWELLNESS@YAHOO.COM PHONE 414-292-3499 FAX 414-292-3494 WESTALLISCHIROPRACTOR.COM HEALTH HISTORY WHAT IF ANY TREATMENT, HAVE YOU RECEIVED? _________________________________________________________ HAVE YOU HAD CHIROPRACTIC CARE BEFORE? YES NO DOCTOR’S NAME _________________________________ IF YES, WAS IT A POSITIVE EXPERIENCE? YES NO ______________________________________________________ NAME OF FAMILY PHYSICIAN OR MEDICAL DOCTOR _______________________________________________________ CHECK YES OR NO TO INDICATE IF YOU HAVE/HAD ANY OF THE FOLLOWING: ABDOMINAL PAIN __Yes __No FRACTURES _______ __Yes __No POLIO __Yes __No AIDS/HIV __Yes __No GALL BLADDER __Yes __No PROSTATE __Yes __No ALCOHOLISM ALLERGIES ANEMIA ANOREXIA ANXIETY APPENDICITIS ARTHRITIS ASTHMA BLEEDING BRONCHITIS CANCER _____________ CATARACTS CHEMICAL DEPENDENCY __Yes __No __Yes __No __Yes __No __Yes __No __Yes __No __Yes __No __Yes __No __Yes __No __Yes __No __Yes __No __Yes __No __Yes __No __Yes __No GLAUCOMA GONORRHEA GOUT HEART DISEASE HEPATITIS HERNIA HERNIATED DISC KIDNEY DISEASE LIVER DISEASE LUNG/RESPIRATORY MEASLES MONO MS __Yes __No __Yes __No __Yes __No __Yes __No __Yes __No __Yes __No __Yes __No __Yes __No __Yes __No __Yes __No __Yes __No __Yes __No __Yes __No PROSETHESIS PSYCHIATRIC RHEUMATOID ARTH RHEUMATIC FEVER SCARLET FEVER SEIZURES STROKE TMJ TUBERCULOSIS TUMORS THYPOID FEVER ULCERS URINARY/BOWEL __Yes __Yes __Yes __Yes __Yes __Yes __Yes __Yes __Yes __Yes __Yes __Yes __Yes CHICKEN POX DEPRESSION DIABETES EMPYSEMA EPILESPY __Yes __Yes __Yes __Yes __Yes NUMBNESS OSTEOPOROSIS PACEMAKER PARKINSON’S PNEUMONIA __Yes __Yes __Yes __Yes __Yes VAGINAL INFECTION __Yes __No __Yes __No __Yes __No __No __No __No __No __No __No __No __No __No __No VENERAL DISEASE WHOOPING COUGH __No __No __No __No __No __No __No __No __No __No __No __No __No OTHER ____________________________________________________________________________________________ FAMILY HISTORY FAMILY MEMBER ___________________ FAMILY MEMBER ___________________ FAMILY MEMBER ___________________ FAMILY MEMBER ___________________ PLEASE CIRCLE: NECK PAIN, BACK PAIN, OTHER ____________________ PLEASE CIRCLE: NECK PAIN, BACK PAIN, OTHER ____________________ PLEASE CIRCLE: NECK PAIN, BACK PAIN, OTHER ____________________ PLEASE CIRCLE: NECK PAIN, BACK PAIN, OTHER ____________________ PLEASE LIST PAST INJURIES/SURGERIES & DATE ___________________________________________________________________________________________________ ____________________________________________________________________________________________________ MEDICATION ALLERGIES ____________________________________________________________________________________________________ CURRENT MEDICATIONS/VITAMINS/HERBS/MINERALS ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ DO YOU EXERCISE NO MODERATE DAILY HEAVY GLASSES OF WATER PER DAY ______ CARBONATED DRINKS PER DAY ______ ALCOHOLIC DRINKS PER WEEK ______ MY STRESS LEVEL IS LOW MODERATE HIGH VERY HIGH MY STRESS COMES FROM ____________________________________________________________________________ ANYTHING ELSE WE SHOULD BE AWARE OF? _____________________________________________________________ 10025 W. GREENFIELD AVE WEST ALLIS, WI 53214 CWELLNESS@YAHOO.COM PHONE 414-292-3499 FAX 414-292-3494 WESTALLISCHIROPRACTOR.COM
