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First Name
Last Name
Address
City
Zip/Postal Code
State/Prov
Home Phone
Cell Phone
Other Phone
Email
Gender
Birthdate
Height
Weight
Marital Status
Spouse
Names/Ages
Num. of Children
Emergency Contact
Relationship
Phone


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How did you hear about us?
Prev. Chiropractor
X-Rays Taken?
Date of Last Visit
Work Status
Employer
Occupation
Phone
Missed work start date
Return or anticipated return date
Extend. Health Cov.

Primary
Company
Policy #
Group #
Who Carries this Policy?
Insured's:
Name
Birth Date
Gender
Patient Address
Phone
Address
City
Zip/Postal Code
State/Prov
Employer
Emp. Phone
Secondary
Company
Policy #
Group #
Who Carries this Policy?
Insured's:
Name
Birth Date
Gender
Patient Address
Phone
Address
City
Zip/Postal Code
State/Prov
Employer
Emp. Phone


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What is your main health concern presently?
Have you seen other doctor(s) for this condition?
Prior Interventions
When did your problem first start?
Have you had this condition before?
Does the pain radiate or travel to other parts of the body?


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Do you have numbness or tingling in any part of your body?
What makes the condition worse?
What makes the condition better?
Does this condition affect mobility?
Does this condition affect employment?
Does this condition affect recreation?
Does this condition affect sleep?
Does this condition affect relationships?


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What else should we know about your current condition?
Rate the severity of your condition from 0 to 10

Mild
Debilitating
Duration of Symptoms
Current Medications
Supplements
Usual Sleep Position
Hours of sleep per night (1-24)
Is your mattress supportive?
Is there a possibility you might be pregnant?


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Type of Pain
Front Head

Type of Pain
Front Face

Type of Pain
Front Left Jaw

Type of Pain
Front Right Jaw

Type of Pain
Front Right Neck

Type of Pain
Front Left Neck

Type of Pain
Front Left Chest

Type of Pain
Front Right Chest

Type of Pain
Front Right Ribs

Type of Pain
Front Left Ribs

Type of Pain
Front Abdomen

Type of Pain
Front Pelvis

Type of Pain
Front Right Hip

Type of Pain
Front Left Hip

Type of Pain
Front Right Thigh

Type of Pain
Front Left Thigh

Type of Pain
Front Right Knee

Type of Pain
Front Left Knee

Type of Pain
Front Right Lower Leg

Type of Pain
Front Left Lower Leg

Type of Pain
Front Right Ankle

Type of Pain
Front Left Ankle

Type of Pain
Top of Right Foot

Please specify specific areas

Type of Pain
Top of Left Foot

Please specify specific areas

Type of Pain
Front Right Shoulder

Type of Pain
Front Left Shoulder

Type of Pain
Front Right Upper Arm

Type of Pain
Front Left Upper Arm

Type of Pain
Front Right Elbow

Type of Pain
Front Left Elbow

Type of Pain
Front Right Forearm

Type of Pain
Front Left Forearm

Type of Pain
Front Right Hand

Please specify specific areas

Type of Pain
Front Left Hand

Please specify specific areas

Type of Pain
Front Right Wrist

Type of Pain
Front Left Wrist

Type of Pain
Back of Head

Type of Pain
Back Right Neck

Type of Pain
Back Left Neck

Type of Pain
Upper Back

Type of Pain
Back Right Shoulder

Type of Pain
Back Left Shoulder

Type of Pain
Mid-Back

Type of Pain
Back Right Ribs

Type of Pain
Back Left Ribs

Type of Pain
Lower Back

Type of Pain
Back Right Hip

Type of Pain
Back Left Hip

Type of Pain
Back Right Glute

Type of Pain
Back left Glute

Type of Pain
Back Right Thigh

Type of Pain
Back Left Thigh

Type of Pain
Back Right Knee

Type of Pain
Back Left Knee

Type of Pain
Back Right Lower Leg

Type of Pain
Back Left Lower Leg

Type of Pain
Back Right Ankle

Type of Pain
Back Left Ankle

Type of Pain
Bottom of Right Foot

Please specify specific areas

Type of Pain
Bottom of Left Foot

Please specify specific areas

Type of Pain
Back Right Upper Arm

Type of Pain
Back Left Upper Arm

Type of Pain
Back Right Elbow

Type of Pain
Back Left Elbow

Type of Pain
Back Right Forearm

Type of Pain
Back Left Forearm

Type of Pain
Back Right Hand

Please specify specific areas

Type of Pain
Back Left Hand

Please specify specific areas

Type of Pain
Back Right Wrist

Type of Pain
Back Left Wrist



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Select options below indicating current or past and other relevant details.
Musculoskeletal
Neurological
Cardiovascular
Respiratory
Digestive


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Sensory
Integumentary
Endocrine
Genitourinary
General


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Personal Illness History
History of Traumas


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Social History
Family History
Mother
Age
Age at Death
Health
Illness
Father
Age
Age at Death
Health
Illness
Sibling
Age
Age at Death
Health
Illness
Sibling
Age
Age at Death
Health
Illness



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What is the most significant thing you can do to improve your health?
How committed are you at achieving your maximum health potential?

Not Interested
Very Interested
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