Name
Address
City
Date
Welcome to Our Office!
Patient Information
Home Phone #:
____________________________________
Social Security #:
___________________________________
Cell Phone #:
____________________________________
Date of Birth:
___________________________________
Employer Name:
____________________________________
Occupation:
____________________________________
Number of Children:___________________________________
Emergency Contact: ________________________________
(Not necessary if it is your significant other)
Employer Phone #: ____________________________________
Relationship:
Marital Status:
Married Single Widowed Divorced
________________________________
(Not necessary if it is your significant other)
(Please Circle One)
Significant Other:
____________________________________
Phone #:
____________________________________
Phone #:
________________________________
(Not necessary if it is your significant other)
Primary Care Provider (PCP)
Name: ___________________________________________________
Phone #:_________________________________________________
Why are you here today?
Chief Complaint
____________________________________________________________
Have you ever been to a chiropractor? Y / N
If yes, when was your last adjustment? _______________
How were you referred? _________________________
Name
Address
City
Date
Condition Information
Mark the areas on your body where you feel your discomfort. Include all affected areas of radiation. If your discomfort
radiates, draw an arrow from where it starts to where it stops. Please extend the arrow as far as it travels. Use the
appropriate symbol(s) listed below.
Ache > > > >
Burning x x x x
Numbness = = = =
Stabbing / / / /
Pins & Needles o o o o
Throbbing ~ ~ ~ ~
When did the condition begin? _________________________________________
Has it ever happened before?
_________________________________________
Have you seen any other doctor for this condition? ____________________
If yes, when was your last treatment? ___________________________________
Is the condition:
___A Result of a Motor Vehicle Accident
MVA Claim Number: ___________________________
___ A Result of a Worker’s Compensation Injury
WC Claim Number: _____________________________
___Other Injury
___No Injury
Quadruple Visual Analogue Scale
1. What is your pain RIGHT NOW?
worst
no pain __________________________________________________________________________________________________________ possible
0
1
2
3
4
5
6
7
8
9
10
pain
2. What is your TYPICAL or AVERAGE pain?
worst
no pain __________________________________________________________________________________________________________ possible
0
1
2
3
4
5
6
7
8
9
10
pain
3. What is your pain level AT ITS BEST (How close to “0” does your pain get at its best)?
worst
no pain __________________________________________________________________________________________________________ possible
0
1
2
3
4
5
6
7
8
9
10
pain
What percentage of your awake hours is your pain at its best? _________%
4. What is your pain level AT ITS WORST (How close to “10” does your pain get at its worst)?
worst
no pain __________________________________________________________________________________________________________ possible
0
1
2
3
4
5
6
7
8
9
10
pain
What percentage of your awake hours is your pain at its worst? _________%
Office Use Only: #1 ______ + #2 ______ + #4 ______ = _______ / 3 x 10 = _________ (Low intensity = <50; High intensity = >50)
Name
Address
City
Date
Review of Systems
Below is a list of diseases, which may seem unrelated to the purpose of your appointment. However, these questions
must be answered carefully as the problems can affect your overall course of care.
Please fill out all sections, even if “None”.
Constitutional:
 None
Chills
 Weight Gain
 Daytime Somnolence
 Weight Loss
 Fatigue
 Fever
 Night Sweats
Eyes/Vision:
 None
 Photophobia
 Blindness
 Eye Pain
 Tearing
 Blurred Vision
 Field Cuts
 Cataracts
 Glasses/Contacts
 Change in Vision
 Glaucoma
 Double Vision
 Itching
ENT:
 None
 Hearing Loss
 Post Nasal Drip (PND)




Respiration:
 None
 Asthma
 Wheezing
 Cough
 Coughing up Blood
 Shortness of Breath (SOB)
 Sputum Production
Cardio:
 None
 Ulcers
 Angina
 Orthopnea
 Varicose Veins
 Chest Pain
 Palpitations
 Claudication
 PND
 Heart Murmur
 SOB with Exertion
 Heart Problems
 Swelling of Legs
Gastro:
 None
 Nausea
 Vomiting




 Belching
 Heartburn
 Regurgitation
 Black Tarry Stools
 Hemorrhoids
 Stool Caliber
 Constipation
 Indigestion
 Stool Color
 Diarrhea
 Jaundice
 Stool Consistency
Female:
 None
 Breast Lumps/Pain
 Urine Retention
 Burning Urination
 Vaginal Bleeding
 Cramps
 Vaginal Discharge
 Frequent Urination
 Irregular Menstruation
Male:
 None
 Burning Urination
 Urine Retention
 Erectile Dysfunction
 Frequent Urination
 Hesitancy/Dribbling
 Prostate
Endocrine:
 None
 Voice Changes
 Cold Intolerance
 Frequent Urination
 Diabetes
 Goiter
 Excessive Appetite
 Hair Loss
 Excessive Hunger
 Heat Intolerance
 Excessive Thirst
 Unusual Hair Growth
Skin:
 None
 Skin Lesions/Ulcers
 Changes in Nail Texture  Changes in Skin Color
 Hives
 Itching
 Varicosities
 Hair Growth
 Paresthesias
 Hair Loss
 Pruritis
 History of Skin Disorders
 Rash
Nervous:
 None
 Stress
 Dizziness
 Loss of Memory
 Strokes
 Facial Weakness
 Numbness
 Tremor
 Headache
 Seizures
 Unsteadiness of Gait
 Limb Weakness
 Sleep Disturbance
 Loss of Conciousness
 Slurred Speech
Psychological:
 None
 Anhedonia
 Confusion
 Anxiety
 Depression
 Appetite
 Insomnia
 Behavioral Change
 Memory Loss
 Bipolar
 Mood Change
Allergy:
 None
 Anaphalaxis
 Food Intolerance
 Itiching
 Nasal Congestion
 Sneezing
Hematology:
 None
 Anemia
 Fatigue
 Bleeding
 Lymph Node Swelling
 Blood Clotting
 Blood Transfusions
 Bruising
Bleeding
Ear Drainage
History of Head Injury



Rhinorrhea (Runny Nose) 
Abdominal Pain
Difficulty Swallowing
Rectal Bleeding
Vomiting Blood
Dentures
Ear Pain
Hoarseness
Sinus Infections




Difficulty Swallowing
Fainting
Loss of Smell
Snoring




Discharge
Frequent Sore Throats
Nasal Congestion
Tinnitus (Ringing in Ear)
 Dizziness
 Headaches
 Nose Bleeds
 TMJ
Name
Address
City
Date
Past Health History
Please fill out the information below carefully as these problems could affect your overall course of treatment.
Childhood Illnesses:
 None
 Measles
 ADD
 Depression
 Mumps
Adult Illnesses:
 None
 Hepatitis
 Similar Symptoms




 Allergies/Hayfever
 Diabetes
 Rash
Anemia
CVA (Stroke)
Hypertension
STD’s




Arthritis
Depression
Kidney Disease
Suicide Attempts
 Asthma
 Fetal Drug Exposure
 Seizure Disorder




Asthma
Diabetes (Insulin Dep)
Liver Disease
Thyroid Problem
 Atopic Dermatitis
 Food Allergies
 Sickle Cell Anemia
 Cerebral Palsy
 Headaches
 Unusual Childhood Illness
 Cancer
 Diabetes (NIDDM)
 Lung Disease
 Chicken Pox
 Eye Problems
 Seizures
Surgeries:
 Angioplasty
 Appendectomy
 Caesarean Section
 Cardiac Catheterization  Carpal Tunnel Release
 None
 Cosmetic
 D&C
 Hemorrhoidectomy
 Hernia Repair
 Hysterctomy
 Joint Replacement
 Laminectomy
 Mastectomy
 Pacemaker Insertion
 Spinal Fusion
 Gallbladder
 Other(s): ______________________________________________________________________________________________________________________________________________________________________
To your knowledge, have you had any diseases, major illnesses, or injuries not indicated on this form either in the past or
present?
Yes
No
(Please Circle One)
If yes, please explain: _________________________________________________________________________________________________
Are there any other conditions we should know about, even if unrelated? ______________________________________
Have you had any previous:
X-ray MRI
CT
Have you had previous Chiropractic care before?
(please circle) Other ____________________________________
Yes
No
(Please Circle One)
If yes, when was your last treatment? ______________________________________________________________________________
Has anyone else in your family experienced this condition?
Yes
No
(Please Circle One)
WOMEN ONLY:
Are you pregnant or is there any possibility that you may be pregnant?
Yes
No
Uncertain
N/A
(Please Circle One)
Social History
Alcohol:
 None
 Beer
 Liquor
 Social Consumption
Diet:
 High Fat Diet
 Low Calorie Intake
 High Fiber
 Low Carbohydrate
 High Protein
 Low Fiber
 High Salt Intake
 Low Salt
Education:
 Level or Degree Attained: ___________________________________________________________________________________________________________________
Substance:
 Denies Any
Tobacco:
Type(s): ___________________________________________________________________________________________________________________________________________
 Denies IV Drugs
Not Used Since:
_________________________________________________