CONFIDENTAIL PATIENT INFORMATION
The following information is needed for our files so we can better serve you as a patient. Please complete this
form and bring it with you to your first appointment. However, do not sign and date the form until you arrive
for your first appointment. If you need help please call our office at 332-4150.
IS VISIT ACCIDENT RELATED?___Yes ___No
Date:___________________
Who referred you to our clinic?_______________________
Name:____________________________________________________________________________________
Home Phone (
)_______________
Work Phone (
)_______________
Cell (
)______________
Address:__________________________________ City:__________________ State:_________ Zip:________
Age:________
Date of Birth:__________
Sex: __ Male __Female
Martial Status: __Married __Single __Divorced __Widowed
Number of children:____
Email address:__________________________
Occupation:________________________________ Employer:______________________________________
Social Security #:____________________________ Spouse’s Social Security #:________________________
Name of spouse:____________________________ Spouse’s Occupation:_____________________________
Spouse’s Employer__________________________
Name of emergency contact or nearest relative not living with you:____________________________________
Address:__________________________________________________ Phone:_________________________
Present complaints – Briefly describe symptoms:__________________________________________________
__________________________________________________________________________________________
When did this condition begin or date of accident:_________________________________________________
List other doctors you have seen for this condition:_________________________________________________
List any operations you have had and the dates:____________________________________________________
Have you ever seen a chiropractor before? ___ Yes ___ No
Doctor’s name and approximate date of last visit:__________________________________________________
Who is your primary care physician?___________________________Date of last physical exam:___________
Have you been treated by a physician for any health condition in the last year? ___ Yes ___ No
Are you allergic to any medication? ___ Yes ___ No If yes, what kind?______________________________
Are you taking any medication? ___ Yes ___ No If yes, what kind?_________________________________
Have you ever had x-rays, MRIs or any other tests of your spine? ___ Yes ___ No When?_______________
Have you ever had surgery on any area of your spine?______________________________________________
List any broken bones or dislocations:___________________________________________________________
Below is a list conditions which may seem unrelated to the purpose of your appointment. However, these questions must be answered
carefully as these problems can effect your overall diagnosis, treatment plan, and the possibility of being accepted for care.
Check any of the following diseases you have had:
□ Alcoholism
□ Alzheimer’s
□ Anemia
□ Appendicitis
□ Arthritis
□ Cancer
□ Chicken Pox
□ Diabetes
□ Diptheria
□ Eczema
□ Epilepsy
□ Goiter
□ Heart Disease
□ HIV
□ Influenza (flu)
□ Malaria
□ Measles
□ Mental Disorder
□ Mumps
□ Osteoporosis/Osteopenia
□ Parkinson’s
□ Pleurisy
□ Pneumonia
□ Polio
□ Rheumatic Fever
□ Scarlet Fever
□ Small Pox
□ Typhoid Fever
□ Tuberculosis
□ Venereal Infection
□ Whooping Cough
Check any of the following you have or have had the past 6 months:
□ Low Back Pain
□ Pain between shoulders
□ Neck Pain
□ Arm Pain
□ Shoulder Pain
□ Leg Pain
□ Joint Pain/Stiffness
□ Walking Problems
□ Difficulty Chewing/Clicking Jaw
□ Headaches
□ Numbness
□ Paralysis
□ Dizziness
□ Forgetfulness
□ Confusion/Depression
□ Fainting
□ Convulsions
□ Cold/Tingling Extremities
□ Allergies
□ Loss of Sleep
□ Fever
□ Poor/Excessive Appetite
□ Excessive Thirst
□ Frequent Nausea/Vomiting
□ Diarrhea
□ Constipation
□ Hemorrhoids
□ Abdominal Cramps
□ Gas/Bloating After Meals
□ Heartburn
□ Black/Bloody Stool
□ Colitis
□ Bladder Trouble
□ Liver Trouble
□ Gall Bladder Problems
□ Weight Trouble
□ Painful/Excessive Urination
□ Discolored Urine
□ Chest Pain
□ Shortness of Breath
□ Blood Pressure Problems
□ Irregular Heartbeat
□ Heart Problems
□ Lung Problems/Congestion
□ Varicose Veins
□ Ankle Swelling
□ Vision Problems
□ Dental Problems
□ Sore Throat
□ Ear Aches
□ Hearing Difficulty
□ Stuffy Nose
□ Menstrual Irregularity
□ Menstrual Cramping
□ Vaginal Pain/Infections
□ Breast Pain/Lumps
□ Prostate Problems
□ Sexual Dysfunction
□ Genital Herpes
FEMALES ONLY:
Date of last period:__________
Are you pregnant? □Yes □No
□Maybe
Why chiropractic? People go to chiropractors for a variety of reasons. Some go 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). Still
others want whatever is malfunctioning in their bodies brought to the highest state of health possible with chiropractic care
(Comprehensive care). Your Doctor will weigh your needs and desires when recommending your treatment program.
Please check the type of care desired so that we may be guided by your wishes whenever possible.
□Relief care □Corrective care □Comprehensive care □Dr. to select type of care appropriate for my condition
I hereby authorize the Dr. to treat my condition as he deems appropriate through use of manipulations, therapy, and such additional
procedures as are considered therapeutically necessary in the course of said treatment. I hereby certify that I have read and fully
understand this Authorization for chiropractic treatment, the reason that the above named treatment is considered necessary, and its
advantages and/or possible complications, if any, as well as possible alternative modes of treatment, which were explained to me by
the Doctor. It is understood and agreed the amount paid the Doctor, for x-rays, is for examination only, and x-ray negatives will
remain the property of this office, being on file where they may be seen at any time while a patient of this office. The Doctor will not
be held responsible for any pre-existing medically diagnosed conditions, nor any medical diagnosis.
Patient’s Signature ____________________________________________________
Guardian or Spouse’s
Signature Authorizing Care______________________________________________
Date_______________
Date_______________
Patient Name:___________________________________________________Date of Birth:________________
Severity of Pain
List the area of pain and circle the number to describe the amount of pain with “1” indicating minor discomfort
and “10” representing severe pain.
1.
2.
3.
4.
5.
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
4
4
4
4
4
5
5
5
5
5
6
6
6
6
6
7
7
7
7
7
8
8
8
8
8
9
9
9
9
9
10
10
10
10
10
Please mark the areas of pain on the drawings below using the listed codes.
Burning (+++)
Stabbing (000)
Sharp (---)
Numbness (###)
Aching (///)
Please list any concerns about your symptoms and anything else you would like the doctor to know:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________