Patient Information form Click Here
Name you would like to called
Marital Status M D W S
How did you hear about me / who referred you.
Describe what you primarily want me to help you with.
Are you under the care of any other health professional for any reason? Yes No
If yes please explain.
Is this your first experience with chiropractic? Yes No
How do you feel about chiropractic?
How long has it been since you felt good?
What kinds of treatments have you tried?
What were the results of the treatment(s).
Have you been diagnosed with a specific problem?
Is condition getting better, worse or the same since it began?
Have you ever had similar condition in the past? Yes No How often?
Is there anything you are unwilling to change to get well?
What do you think has prevented you from getting well in the past?
Please list here what has helped you in the past; what has helped in the past but no longer works and what if anything has made you worse.
What do you believe is a reasonable time frame to resolve this complaint you are asking for help with today?
Accidents or Injuries (describe, location, date/time occurred)
Stress Factors physical psychological chemical
Do you follow a regular exercise program? Yes No
Sleep Excellent Fair Poor
Appetite Excellent Fair Poor
Bowels Move __/ Day/Wk
Excellent Fair Poor
Any gas bloating or discomfort after eating. Yes No
Would you say your digestion is Excellent Fair Poor
Water - glasses per day
Coffee - cups per day
Alcohol per day
Tobacco per day
Soda Drinks per day
Black Tea - cups per day
Sugar - per day
Recreational Drugs Yes No
Do you have a certain craving for foods or tastes? Yes No
Explain if yes
Do you crave food, drink or environments that are hot or cold? Yes No
Would others say you are mostly Happy Easily Irritable Angry Depressed Worried Fearful
Please list all medications taken & reason (prescription, vitamin, herbal)
**Please put a check next to any conditions you have experienced within the last 3 months.
Sleep no complaints hard to fall asleep night urination__/night Wake during night
no complaints low low after eating high up and down high in the afternoon
no complaints warm natured cold natured cold hands and feet sweat easily night sweats feel warmer late afternoon and night flushed face warm palms
no complaints headaches poor memory dizziness
no complaints corrective lenses color blindness eye pain cataracts excessive tearing eye dryness
no complaints nasal discharge mucous bleeding loss of smell stuffy nose sinusitis
no complaints discharges pain poor hearing ringing
no complaints gum/teeth problems difficulty swallowing dry frequent colds TMJ root canals or major dental work
Skin and Hair
no complaints dry oily dandruff falling out early grey rashes itching hives pimples ulcerations bruise easily
Muscles and Bones
no complaints pain in: neck upper back lower back elbow hands knees foot/ankle muscular pains muscle weakness
no complaints asthma trouble breathing coughing with phlegm dry cough chest pain tightness in chest wheezing shortness of breath
no complaints high blood pressure low blood pressure palpitations varicose veins bleed easily chest discomfort ankle swelling
no complaints vomiting belching indigestion distention of abdomen after eating problems with fatty or oily foods constipation diarrhea/loose stools gas
no complaints bad temper loss of control/violence potential depression treated for emotional problems in the past ever considered suicide or attempted suicide easily susceptible to stress
Do you use birth control? Yes No
Painful or tender breasts? Yes No
Do you have beast implants? Yes No
Ever been raped or sexually molested? Yes No
Premature Births Miscarriages
Irregular light heavy menstrual flow? No Post-menapause
Painful Menses? Yes No