Cleveland Chiropractic & Wellness Center
Dr. Emily Arnold-Wheat
2460 Fairmount Blvd.
The Heights Medical Building, Unit B
Cleveland Hts., OH 44106
Patient Title:
___ Mr. ___ Mrs. ___ Ms. ___ Miss ___ Dr. ___ Prof. ___ Rev.
First Name________________________
Date of Birth ____/_____/_____
Last Name________________________
Gender ___ Male ___ Female
Address___________________________
SSN: ____- ____- _______
City________________________________
Driver License # ___________
State_____ Zip Code ________
Marital Status: ___Single ___ Married ___ Other
Primary Phone_____________________
Mobile Phone______________________
Emergency Contact: _______________
Email_______________________________
Relationship to Patient: _____________
Primary Phone: ___________________
By providing my email address, I authorize my doctor to contact me via email.
Race:
______Caucasian
______Hispanic or Latino
______American Indian or Alaska Native
______ Native Hawaiian or Other Pacific Islander
______ I choose not to specify
_____ African American
_____Asian
_____Multi-Racial
_____Other
Preferred Language: ___________________
How did you hear about us: ______________________
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Cleveland Chiropractic & Wellness Center
Dr. Emily Arnold-Wheat
2460 Fairmount Blvd.
The Heights Medical Building, Unit B
Cleveland Hts., OH 44106
Medical History
List current medications and vitamins including frequency and dosage, if known. If there are no
current medications or vitamins being taken, check here: ______
Medication/Vitamins
Why are you taking this
(ie 1 tablet/5mg)
Frequency
(ie 2 times/day)
Start
Date
Smoking and Allergy History
Do you currently smoke tobacco of any kind?
_____Yes
____No If yes, how many cigarettes per day? _____
Do you have any allergies?
____ Yes ____ No
If yes, please list any known allergies:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Social History
Employer’s Name: _____________________
Job Title and Description:
______________________________________________________________________
What do you do most of the day at work?
____ Sit ___Stand ___Light Labor ___Heavy Labor ___ Other
How often do you consume alcohol or use recreational drugs? _________
What kind? _________________________________________________
Cleveland Chiropractic & Wellness Center
Dr. Emily Arnold-Wheat
2460 Fairmount Blvd.
The Heights Medical Building, Unit B
Cleveland Hts., OH 44106
Health Review
How many hours of sleep are you getting per night? Is your sleep routine?
___Less than 5 ___6-8 ___8-10 ___10 or more
Do you have trouble falling to sleep? Staying asleep?
How would you rate your sleep on the following scale?
No/Poor Sleep 1 2 3 4 5 6 7 8 9 10 Fully Rested
How many days a week do you exercise for 30 minutes or more?
____ Days
How would you rate your stress level?
Low 1 2 3 4 5 6 7 8 9 10 High
List your major stressors:
_____________________________________________________________________________
What are your expectations for care at Cleveland Chiropractic and Wellness Center?
_____________________________________________________________________________
_____________________________________________________________________________
Injuries: (List date next to injury)
___ Back injury
___ Broken bones
___ Disability (ies)
___ Fall (severe)
___ Fracture
___ Head injury
___ Industrial accident
___ Joint injury
___ Laceration (severe)
___ Motor vehicle accident
___ Soft tissue injury
___Stroke
___ Other: _______
Are you currently under the care of any doctor
for your condition?
___ Yes, Dr. __________________________
___No
Have you seen a chiropractor in the past?
___Yes
___No
Date of last visit____/____/_____
Name of previous
Chiropractor______________
Were you satisfied with your care?
___Yes
___No
Why?
__________________________________
Cleveland Chiropractic & Wellness Center
Dr. Emily Arnold-Wheat
2460 Fairmount Blvd.
The Heights Medical Building, Unit B
Cleveland Hts., OH 44106
What is your chief complaint today?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Have you had any serious illnesses?_______________________________________
Do you have any food allergies?__________________________________________
Please list all surgeries you have had:
____________________________________________________________________________________
________________________________________________________
On a scale of 1 to 10, what is your present energy level?
Worst 0 1
2
3
4
5
6
7
8
9
10 Best
Bowel Movements
Number per day?______
Hard?______
Number per week?______
Small marble size?______
Well formed?______
Runny/loose?______
Please check any of the following you have currently or have
had in the past:
___Abnormal Heart Problems
___HIV/AIDS
___Anemia
___Aneurysm
___Appendicitis
___Arteriosclerosis
___Arthritis
___Asthma
___Auto-Immune Disease
___Cancer
___Chest Pains
___Circulatory Problems
___Cold Sores
___Diabetes
___Dizziness
___ Disc Problems
___Emphysema
___Epilepsy
___Eye Pains
___Fever Blisters
___Female Hormonal issues
___Frequent Colds
___Frequent Urination
___Lupus Erythema
___Psoriasis
___Unspecified Pleural Effusion
___STD’s (unspecified)
___Vertigo
___Other:______________
___Goiter
___Gout
___Heart Murmur
___Hepatitis
___Hernia
___Herpes
___Hypersensitivity
___Painful Menstruation
___Painful Intercourse
___Pneumonia
___Sinus Problems
___Skin Infections
___Stroke
___Tuberculosis
___Influenza
___Excessive Bleeding
___Light Headedness
___Lupus
___Malignancies
___Measles
___Migraines
___Miscarriage
___Multiple Sclerosis
___Mumps
___Nervous Problems
___Venereal Infection
___Alzheimer’s
___Cerebral Palsy
___Chicken Pox/Shingles
___Colitis
___CRPS (RSD)
___CVA (Stroke)
___Cystic Kidney Disease
___Depression
___Eczema
___Fibromyalgia
___Night-Time Urination
___Nosebleeds
___Psychiatric Problems
___Multiple Sclerosis
___Psychiatric Condition
___Seizures
___Suicide Attempts
___Hypertension
___Heart Disease
___High Blood Pressure
___Liver Disease
___Parkinson Disease
___Scoliosis
___Shingles
___Thyroid Problems
Disclaimer
Your nutritional-wellness care plan in this office is not designed to
replace, negate or cancel out the medical care plan prescribed by your
primary care physician. Instead, it is designed as an alternative health
care adjunct to incorporate food, supplements, vitamins, lifestyle
changes, and herbal regimens to assist you in achieving your health and
wellness goals. Nutritional counseling, vitamin recommendations,
nutritional advice and the adjunctive schedule of nutrition is provided
solely to upgrade the quality of foods in the patient’s diet in order to
supply good nutrition supporting the physiological and bio-mechanical
processes of the human body. Your health is ultimately your
responsibility and therefore our treatment regimens are highly suggested
plans yielding highly favorable outcomes, depending upon your full
compliance and adherence. The wellness plans are uniquely designed
for your individual case. Our method of wellness care is supported by
the results of clinical and cutting edge scientific research. Therefore, the
products recommended in your health and wellness plan have not been
regulated by the FDA as they are not classified as drugs.
Patient signature:_________________________ Date:____________