Patient ID 
Nonnenmacher Chiropractic
9986 Spotswood Trail
McGaheysville, VA 22840
Date
Patient First Name________________________ MI ____ Last ____________________________________
Sex: M / F
Address___________________________________________City________________________State_______ZIP______________
Relationship status - circle one:
Single
Married
Widow Separated
Divorced
Significant Other
____# of Children
Soc. Sec# _________-_________-__________ D.O.B. ____/____/______ E-mail:________________________________________
Home # (____)__________________
Wk# (____)________________________ Cell # (____)_____________________________
Verizon AT&T Sprint Altel Other ________________
Your employer _________________________________ Your occupation ________________________________________________
Are there any medical conditions that the doctor should address? If so, list and describe:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Medications: What medications are you currently taking and for what conditions?
____________________________________________________________________________________________________________
Allergies: If yes, what type: _____________________________________________________________________________________
Surgeries and major accidents If yes, list and describe: _______________________________________________________________
____________________________________________________________________________________________________________
Seeking treatment due to an accident? ___ Yes ____ No
If Yes:
____Auto _____Work _____Other
When did you first notice this problem? _________________________ Have you had this problem before? ____ Yes ____ No
What treatment have you already received for your condition? ____ Medication ____ Surgery ____ Physical Therapy _______ Other
What solutions have you attempted to solve this problem? ___________________________________ ________________________
Have you ever been to a Chiropractor before?
___ Yes ____ No
If Yes: Date of your last adjustment_______________________
What is your objective with coming to our office? _____ Family Wellness _____ Spinal Maintenance _____ Symptom Relief
FAMILY HISTORY List any of the diseases which run in your family
Relative
Father
Mother
Brother(s)
Sister(s)
Grandfather
Grandmother
Age if
living
Illness(es)
Age of
Death
Cause of Death
Patient ID 
Nonnenmacher Chiropractic
9986 Spotswood Trail
McGaheysville, VA 22840
Date
On the diagram below, mark the area on your body where you feel the described sensation(s)
KEY
D/A
N
W
P/N
S
SB
B
SP
Dull pain/Aching
Numbness
Weakness
Pins and Needles
Stiffness
Stabbing
Burning
Sharp Pain
Indicate the area (i.e. neck, low back) where you feel your discomfort. 0 is no pain/ discomfort and 10 is worst possible
pain/discomfort imaginable. Then indicate if the pain is constant or intermittent by circling the appropriate word.
Area___________________________________________ On Average:______/10; At worst:______/10 Constant or Intermittent
Area___________________________________________ On Average:______/10; At worst:______/10 Constant or Intermittent
Area___________________________________________ On Average:______/10; At worst:______/10 Constant or Intermittent
GENERAL PAIN INDEX WITH DAILY ACTIVITIES: On a scale of 0-10 Please rate the discomfort you experience when performing the
following activities:
Walking
Bending
Sleeping
Running/jogging
Carrying
Driving
Reading
Household Chores
Sports
Sitting to Standing
Other:
Sitting
Standing
Lifting
Climbing Stairs
Pushing/Pulling
Dressing
Watching TV
Gardening
Employment
Computer Work
Patient ID 
Nonnenmacher Chiropractic
9986 Spotswood Trail
McGaheysville, VA 22840
Date
Your Health Profile
Please indicate if you have experienced the following health issues never, currently (within 3 months) or in
the past (3 months or more):
General
Never
Current
Cardiovascular
Past
Never
Current
Past
Allergies
Cancer TYPE
Cold Sweats
Convulsions/Epilepsy
Diabetes
Dizziness/Vertigo
Fatigue
Frequent Colds/ Flu
Headaches/Migraines
Skin Problems
Anemia
Chest Pain
Cold Feet
Cold Hands
Heart Problems
High Blood Pressure
Eyes, Ears & Nose
Never
Current
Past
Buzzing/Ringing in ears
Blurred Vision R / L
Stroke
Tremors
Double Vision R / L
Light Bothers Eyes
Emotional
Never
Current
Loss of Balance
Past
Loss of Smell
Loss of Taste
Sinus Problems
Anxiety/Nervousness
Depression
Irritability/Mood Swings
Digestive
Sleeping Problems
Tension/Stress
Never
Current
Past
Colon Trouble
Urinary
Never
Diarrhea/Constipation/Gas
Current
Past
Digestive Problems
Heartburn/reflux
Stomach Upset
Bed Wetting
Gall Bladder Problems
Kidney Trouble
Muscle & Joint
Problems Urinating
Never
Current
Past
Respiratory
Never
Current
Arthritis
Back Stiffness/Pain
Past
Lung Problems
Pain w/ Cough/ Sneeze
Shortness of Breath
Fractured Bones
Hip Pain R / L
Jaw/TMJ Problems
Women’s Health
Neck stiffness/ Pain
Never
Swollen Painful Joints
Current
Past
Hot Flashes
Menopause
PMS
Men’s Health
Never
Current
Past
Prostate Problems
Patient ID 
Nonnenmacher Chiropractic
9986 Spotswood Trail
McGaheysville, VA 22840
Date
Social History
Check the boxes and fill in
Current Weight____________ Have you recently lost or gained weight?_______________________
Mental Work
___ Yes ____ No
If Yes: ____ Heavy ____ Moderate ____ Light
Hours per day___________
Physical Work ___ Yes ____ No
If Yes: ____ Heavy ____ Moderate ____ Light
Hours per day___________
Hobbies/Recreation _______________________________________________________________________________________
Exercise
___ Yes ____ No
If Yes: ____ Heavy ____ Moderate ____ Light
Smoking
___ Yes ____ No
If Yes: ____# Packs/Day
Alcohol
___ Yes ____ No
If Yes: ___ Beer/Week ___ Liquor/Week ___ Wine/Week ___ Number of years
Caffeine (coffee, tea, cola) ___ Yes ____ No
Aspirin
Hours per day___________
____ Number of years ____
If Yes: ___ Cups/Day ____ Number of years
___ Number per Day
Other___________________________________________________________________________________________________
Who may we thank for referring you to our office?
______________________________________________________________
I hereby certify that the statements and answers given on this form are accurate to the best of my recollection and knowledge. I
agree to allow this office to examine me for further evaluation.
____________________________________________
Signature
_____/_____/_________
Date