Back In Motion Chiropractic
PATIENT INFORMATION
Today's Date:
Primary Physician:
Last Name:
First Name:
DOB:(mm/dd/yy) Sex:
Marital Status:(circle one)
M
F
single / mar / com law / wid
Mailing Address, City, Province, Postal Code
Home Phone:
Email Address:
Cell Phone:
Reminders? (If YES, circle one)
Chose clinic because/referred to clinic by: (please circle one)
Facebook
Newspaper
Phone Book
Website
Flyer
Saw Sign
EMERGENCY CONTACT
Name:
Home Phone #:
Relationship to patient:
Work/Cell Phone #:
Kids? How many?
Y
N
Email
Cell
Close to home/work
Person:
Chief Complaint(explain)
How long have you had this condition?
Is it getting worse? Y
N
Initial cause?
Caused by Auto Accident? Y
N
Caused by Work Injury? Y
N
Do you have any other health issues or concerns that our staff should be made aware of?
Back In Motion Chiropractic
General
 Allergies
 Alcoholism
 Anemia
 Atheriosclerosis
 Asthma
 Bleeding problems
 Bronchitis
 Cancer
 Chicken pox
 Chills
 Cold sores
 Depression
 Diabetes
 Eczema
 Edema
 Emphysema
 Epilepsy
 Fatigue
 Fever
 Goiter
 Gout
 Heart burn
 Heart disease
 Hepatitis
 Herpes
 High cholesterol
 HIV/AIDS
 Influenza
 Loss of sleep
 Malaria
 Measles
 Miscarriage
 Multiple sclerosis
 Mumps
 Night Sweats
 Nervousness
 Numbness/tingling
 Osteoporosis
 Pace maker
 Polio
 Thyroid disease
 Ulcers
 Weight loss/gain
Cardiovascular
 High blood pressure
 Low blood pressure
 Hardening of the
arteries
 Irregular pulse
 Pain over heart
 Palpitation
 Poor circulation
 Rapid heart beat
 Rheumatic fever
 Slow heart beat
 Stoke
 Swelling of ankles
Eye, Ear Nose & Throat
 Poor vision
 Eye pain
 Hearing problems
 Earaches
 Ringing in ears
 Nosebleeds
 Nose problems
 Sinus trouble
 Dental problems
 Hoarseness
 Sore throat
 Tonsillectomy
Gastrointestinal
 Abdominal pain
 Appendicitis
 Bloody or tarry stool
 Belching or Gas
 Colitis/Chrohn's
 Colon trouble
 Constipation
 Diarrhea
 Difficulty
swallowing
 Diverticulitis
 Bloated abdomen
 Excessive hunger
 Gallbladder trouble
 Hernia
 Hemorrhoids
 Intestinal worms
 Jaundice
 Liver problems
 Nausea
 Painful defecation
 Poor appetite
 Poor Digestion
 Vomiting
 Vomiting of blood
Genitourinary
 Bed-wetting
 Bladder infection
 Blood in urine
 Decreased flow/force




Kidney infection
Kidney stones
Frequent urination
Overnight more than
twice
 Painful urination
 Prostate trouble
 Pus in urine
 Stress incontinence
 Sexual difficulties
 Urgency to urinate
Musculoskeletal
 Arthritis/rheumatism
 Foot trouble
 Muscle weakness
 Neck pain
 Low back pain
 Mid back pain
 Joint pain
 Muscle
ache/soreness
 Spinal curvature
Neurologic
 Weakness
 Twitching
 Tremor
 Headache
 Fainting
 Dizziness
 Convulsions
 Epilepsy/Seizures
 Numbness/Tingling
 Arm/leg pain
 Mental disorder
Skin
 Bruise easily
 Changes in mole(s)
 Dryness
 Hives or allergies
 Itching
 Rash
 Scars
 Varicose veins
Respiratory
 Chest pain
 Chronic cough
 Difficulty breathing
 Shortness of breath
 Spitting up
phlegm/blood
 Pneumonia
 Tuberculosis
 Wheezing/Asthma
WOMEN ONLY
 Congested breasts
 Hot flashes
 Lumps in breast
 Menopause
 Vaginal discharge
 Painful periods
 Excessive Flow
 Irregular cycles
Date of last Period
Date of last PAP
Date of last mammogram
Are you pregnant? Y N
Habits







Smoking #pack/day
Drinking
Recreation drug use
Caffeine
Soft drinks
Artificial sweeteners
Exercise
#times/week
Trauma
 Car accident
 Major fall
 Broken bones
 Sprain/strains
 Head trauma
 Sport injury
 Surgeries
Family History
 Arthritis
 Cancer
 Diabetes
 High BP
 High cholesterol
 Heart disease
 Kidney disease
 Lung disease
 Muscle, bone, or
nerve disease
 Seizure/Stroke
 Thyroid disease
 Tuberculosis
 Ulcers
Back In Motion Chiropractic
Informed Consent to Chiropractic Treatment
There are risks and possible risks associated with manual therapy techniques used by doctors of
chiropractic. In particular you should note:
a) While rare, some patients may experience short term aggravation of symptoms or muscle and
ligament strains or sprains as a result of manual therapy techniques. Although uncommon, rib
fractures have also been known to occur following certain manual therapy procedures;
b) There are reported cases of stroke associated with visits to medical doctors and chiropractors.
Research and scientific evidence does not establish a cause and effect relationship between
chiropractic treatment and the occurrence of stroke. Recent studies suggest that patients may be
consulting medical doctors and chiropractors when they are in the early stages of a stroke. In
essence, there is a stroke already in progress. However, you are being informed of this reported
association because a stroke may cause serious neurological impairment or even death. The
possibility of such injuries occurring in association with upper cervical adjustment is extremely
remote;
c) There are rare reported cases of disc injuries identified following cervical and lumbar spinal
adjustment, although no scientific evidence has demonstrated such injuries are caused, or may be
caused, by spinal adjustments or other chiropractic treatment;
d) There are infrequent reported cases of burns or skin irritation in association with the use of some
types of electrical therapy offered by some doctors of chiropractic.
I acknowledge I have read this consent and I have discussed, or have been offered the opportunity to
discuss, with my chiropractor the nature and purpose of chiropractic treatment in general, (including
spinal adjustment), the treatment options and recommendations for my condition, and the contents of this
Consent.
I consent to the chiropractic treatment recommended to me by my chiropractor including any
recommended spinal adjustments.
I intend this consent to apply to all my present and future chiropractic care.
Dated this_____________ day of_________________________, 20_________.
______________________________
Patient Signature (Legal Guardian)
____________________________________
Witness of Signature
Name:__________________________
(please print)
Name:______________________________
(please print)