CONSENT TO EXAMINATION AND DETERMINATION OF A CHIROPRACTIC CASE
The taking of a history and physical examination are not considered treatment, but are part of the process to determine if your case will
benefit from chiropractic care. If Dr. Hughlett or any Associate Doctor does not believe that your condition will respond to chiropractic
care, she/he will not accept you as a patient but will, if appropriate, refer you to another health care provider. If your case requires
immediate attention, emergency first aid and/or therapeutic adjunctive procedures will be performed. I hereby request/authorize Dr.
Michael Hughlett, and/or any Associate Doctor to perform diagnostic examination tests and x-rays, and if necessary, to
perform emergency first aid and/or therapeutic procedures to  myself. /my minor child:
Signature:
Date:
PATIENT INFORMATION
PATIENT NAME:
TODAY’S DATE:
Age:
Sex: Female / Male Past Chiropractic Care No / Yes: When?
Previous Chiropractor’s Name:
Results?
Are your present problems due to an injury? No/ Yes: On the Job Auto Accident Personal Injury
Other:
Has the accident been reported? No / Yes: to Employer to Auto Carrier Other:
Are you now or have you ever been disabled? (service or work)? No / Yes: When?
Why?
Have you retained an attorney? No / Yes: Name & Address:
HISTORY OF PRESENT ILLNESS
Chief Complaint:
When did it first start:
How long does it last?
What make it worse?
What make it feel better?
Does it hurt more in the morning, afternoon or evening? Explain:
Has this ever happened before? Explain:
Are you taking any medication for this pain?
Are there other associated problems?
Please circle the intensity for the
Please mark area & type of discomfort on the drawing using the codes below:
pain you described above:
N=Numbness
1. Chief Complaint:
ST=Stiffness
1 2 3 4 5 6 7 8 9 10
S=Soreness
2. Associated Problems:
A=Ache
1 2 3 4 5 6 7 8 9 10
T=Tingling
3. Associated problems:
P=Pain
1 2 3 4 5 6 7 8 9 10
OPERATIONS AND PROCEDURES
 I have never had any operations/surgeries.
Prior Surgery and Dates:
Vaccinations:
Tubes in Ears:
Sinus:
Stomach:
Appendectomy:
 Hernia:
Thyroid:
Back Operation:
Rectal Surgery:
Tonsillectomy: _______
Female Organs:
 Gall Bladder:
HAVE YOU HAD, OR DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS?
Mental Disorder
Whooping Cough
Migraine Headaches
Heart Disease
Cancernn Anemianm Pleurisy n
Polionnn Asthmannn Influenzam
Goiternn DiabetesnnnMumpsmn
Arthritism HIV Positive  Epilepsy
Pneumonia
Measles
Eczema
Chicken Pox
Appendicitis Alcoholism
Tuberculosis Lumbago
Venereal Disease
Multiple Sclerosis
 Rheumatic Fever
Herpes
SOCIAL HISTORY
Marital Status: Single Married Widowed 
Divorced
Alcohol Use: No / Yes: How Much?
Tobacco Use: No / Yes: How Much?
Activity: Sitting Standing Light Labor Heavy Labor
Occupation:
Caffeine Use: No / Yes: How Much?
Exercise: None Light Activity Moderate Activity Work
Active Very Active Elite Athlete
REVIEW OF SYSTEMS
Please check the correct
box for each item below.
-Previously
-Presently
General Symptoms
-Allergy (what)
Respiratory
-Chest Pain
-Chronic Cough
-Difficulty Breathing
-Spitting Blood
-Spitting Phlegm
-Bronchitis
-Chills
-Convulsions
-Dizziness
-Fainting
-Fatigue
-Fever
-Headache
-Loss of Sleep
-Loss of Weight
-Nervousness
-Neuralgia
-Sweats
-Wheezing
-Depression
Gastro-Intestinal
- Belching/
Gas/Bloating
-Abdominal Pain
-Constipation
-Diarrhea
-Excessive Eating
-Gall Bladder Trouble
-Hemorrhoids (piles)
-Jaundice
-Liver Trouble
-Nausea
-Stomach Pain
-Poor Appetite
-Poor Digestion
-Vomiting
-Vomiting Blood
-Excessive Thirst
-Indigestion
-Rectal Bleeding
Muscles/Joints/Bones
-Backache
-Foot Trouble
-Hernia
-Pain Between
Shoulders
-Painful Tail Bone
-Stiff Neck
-Spinal Curvature
-Swollen Joints
-Tremors/Twitching
-Arm Trouble
Eye/Ear/Nose/Throat
-Asthma
-Crossed Eyes
-Deafness
-Earache
-Ear Discharge
-Ear Noises
-Enlarged Thyroid
-Frequent Colds
-Hay Fever
-Hoarseness
-Nasal Obstruction
-Nosebleeds
-Pain in Eyes
-Poor Vision
-Sinusitis
-Sore Throat
-Tonsillitis
-Persistent Cough
-Difficulty Swallowing
-Bleeding Gums
Cardio-Vascular
-High Blood Pressure
-Low Blood Pressure
-Pain Over Heart
-Poor Circulation
- Heart Trouble
-Rapid Heart
-Slow Heart
-Strokes
-Swelling Ankles
Skin or Allergies
-Boils
-Bruising Easily
-Dryness
-Eczema
-Hives or Allergy
-Itching
-Sensitive Skin
-Skin Eruptions
Genito-Urinary
-Bed Wetting
-Blood in Urine
-Frequent Urination
-Lack of Bladder
Control
-Kidney Infection
-Painful Urination
-Prostate Trouble
For Women Only
-Cramps or
Backaches
-Excessive Flow
-Hot Flashes
-Irregular Cycle
-Miscarriage
-Painful Periods
-Vaginal Discharge
-Lump in Breast
Pregnant at this time?
Yes/No
Last Menstrual Period?
Last PAP?
By whom?
Have you had a
mammogram?
Yes/No
# of Pregnancies
# of Deliveries
PAST HISTORY
List any accidents or falls and dates: Car
Recreation
Sports
School
Other
List any broken bones (fractures) or dislocations:
Have you ever been on crutches? No / Yes Why?
Have you ever had spinal taps or spinal injections? No / Yes
Were you ever knocked unconscious? No / Yes
Have you ever had a lapse of memory? No / Yes
Have you ever had x-rays taken? No / Yes: When?
By Whom?
For what ailments were these x-rays taken?
Do you suffer from any condition other than that which you are now consulting us?
Are you presently taking any medications – prescription or over-the-counter? No / Yes: Please list:
FAMILY HISTORY
Mother
Father
Brother, #
Sister, #
of
of
Diabetes Heart Attack High Blood Pressure
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NOTES
Kidney Cancer Other
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