Client Questionnaire
Name
Phone
Address
Email
Sex
DOB
Age
Emergency contact #
Referred by
1. Have you ever had or do you currently have (Please write YES for the ones
that apply to you)
High blood pressure
Heart or circulation disorders
Seizure
Dizzy spells
Diabetes
Degeneration joint disease
Arthritis/Osteoarthritis
Scoliosis
Osteoporosis
Auto immune deficiency disease
Asthma
Direct injury or trauma to head
or neck
Joint swelling and stiffness
Cancer/tumors
Chronic fatigue syndrome
Fibromyalgia
Thyroid condition
Do you get itchy, red eyes
High cholesterol
Recent infections
Neuropathy
Location of
neuropathy
Smoking history
Back problems
Neck problems
Car
accident/whiplash
Headaches
Vertigo
Difficulty with
concentration
Fear of speed or
crowds
Car sickness/sea
sickness
Do you have the
impression of
clenching during
the day or at
night?
Average hours of
sleep per night
ADD/ADHD
Learning
difficulties
Are you taking
antidepressants
Do you have memory problems
Are you clumsy
2. Please list surgeries you have had. Please give procedures and dates if
possible and include dental work:
3. When did you have you last eye exam:
4. Please list recent diagnostic studies (CT-scan, MRI, X-Rays):
5. Do you have any metal or silicone anywhere in your body: pins/plates, postfracture, pacemaker, implants, major dental work:
6. Did you ever have cranial trauma or cervical strain:
7. Please list any current medications, self prescribed medications, or dietary
supplements that you are taking:
8. Do you wear or have you worn foot orthotics or a mouth guard at night:
9. Are you trying to get pregnant or currently pregnant? If so, how far are you
into your pregnancy:
10. Have you had steroid or cortisone shots? How many different shots, how
many years ago and where did you have the shots in your body:
11. What is your reason for consultation:
12. What are you physically doing at work? Is your job highly stressful?
13. Describe your activity level with a detailed list of the activities you are
currently involved in:
14. Does your insurance plan cover the cost for treatment?