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Section 1: Demographics
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Indicates required field
Name:
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First
Last
Prefers to be called:
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Birth date (mm/dd/yyyy):
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Height:
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Weight:
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Age:
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Gender
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Male
Female
Home Address:
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Line 1
Line 2
City
State
Zip Code
Country
Home Phone Number
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Cell Phone Number:
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Email Address:
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Preferred Method of Contact:
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Home Phone
Cell Phone
E-mail
Marital Status
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Single
Married
Divorced
Widowed
Other
Spouse's Name:
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Number of Children:
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Children's Names and Ages:
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Are you currently pregnant?
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Yes
No
N/A
Occupation/Job Description:
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Emergency Contact Name:
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Emergency Contact Phone
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Emergency Contact Relationship:
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How were you referred to our office?
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Section 2: Your Symptoms
I am here for a specific issue:
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Yes
No
If No, please go directly to section 3.
What has prompted you to seek care today?
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This is the result of:
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An accident or injury
A worsening long-term problem
Other
When did you first begin to notice your symptoms?
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Where are you feeling the symptoms?
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Quality of Symtoms: (What does it feel like?)
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Dull
Achy
Numbness
Tingling
Stiffness
Sharp
Cramping
Nagging
Burning
Shooting
Throbbing
Stabbing
Other
Prior Interventions: (What have you done to try and relieve the symptoms?)
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Have you missed any work due to your symptoms?
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Yes
No
How have your symptoms affected your daily activities or routines?
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Have you had x-rays taken for this condition?
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Yes
No
If yes, where & when?
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Section 3: Personal Health History
A. Musculoskeletal:
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Osteoporosis
Knee Injuries
Arthritis
Gout
Foot/Ankle Pain
Scoliosis
Shoulder Problems
Hip Disorders
Neck Pain
Elbow/Wrist Pain
Back Problems
TMJ Issues
D. Respiratory:
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Asthma
Shortness of Breath
Sleep Apnea
Pneumonia
Hay Fever
Emphysema
G. General:
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Appetite Changes
Low Libido
Cancer
Eating Disorder
Concussion
B. Neurological:
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Anxiety
Dizziness
ADD/ADHD
Depression
Seizures
Confusion
Headache
Numbness
Loss of Balance
G. Skin:
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Skin Cancer
Psoriasis
Eczema
Hair Loss
Rash
H. For Females Only:
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Difficulty Conceiving
Breast Tenderness
Irregular Periods
Breast Implants
Painful Periods
PMS Issues
C. Cardiovascular:
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High Blood Pressure
Low Blood Pressure
Irregular Heart Beat
High Cholesterol
Excessive Bruising
Pacemaker
Angina
Poor Circulation
Stroke
H. Endocrine:
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Thyroid Issues
Immune Disorder
Hot Flashes
Frequent Infection
Low Energy
Swollen Glands
I. For Males Only:
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Prostate Issues
Impotence
Hernia
D. Digestive:
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Food Sensitivities
Digestion Problems
Gallbladder Disease
IBS
Ulcer
Constipation
Diarrhea
Heartburn
F. Urinary:
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Kidney Stones
Frequent Urination
Bedwetting
Please list any surgeries or past surgical interventions:
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Past Injuries - Do you have a history of any of the following?
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Fractured or broken bone
Spine or nervous system disorder
Being knocked unconscious
Injury in an accident
Bad fall or injury
Other
None of the above
Please list any medications you are taking with reason for use (prescription and over the counter):
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Please list any nutritional supplements/vitamins you are currently taking:
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Please check the treatments you have received in the past, or are receiving currently:
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Acupuncture
Chemotherapy
Chiropractic
Dialysis
Herbal Remedies
Homeopathy
Massage Therapy
Physical Therapy
Other
Are you currently seeing a primary care medical doctor?
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Yes
No
If yes, who is your Medical Doctor?
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Section 4: Personal Health Habits & Lifestyle
How often do you use the following:
Alcohol
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Everyday
Once per week
2 to 3 times per week
Once per month
Less than once per month
Never
Coffee
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Everyday
Once per week
2 to 3 times per week
Once per month
Less than once per month
Never
Energy Products
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Everyday
Once per week
2 to 3 times per week
Once per month
Less than once per month
Never
Soft Drinks
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Everyday
Once per week
2 to 3 times per week
Once per month
Less than once per month
Never
Drugs
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Everyday
Once per week
2 to 3 times per week
Once per month
Less than once per month
Never
Exercise
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Everyday
Once per week
2 to 3 times per week
Once per month
Less than once per month
Never
Please rate your stress level on a scale from 0-10 (0=no stress and 10=extremely high stress):
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Section 5: Health Goals
People seek chiropractic care for a variety of reasons. Some people seek symptom relief, others want to correct the cause of the symptoms, and some are seeking to better their health in general. In our office, you and the doctor will discuss your health and current health issues, and choose a plan that is best for your needs.
As of right now, let us know what type of care you are seeking:
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Relief Care: Symptomatic relief of pain or discomfort (a temporary fix to an underlying problem)
Corrective Care: Correcting and relieving the cause of the problem, as well as the symptoms arising from it
Comprehensive Wellness Care: Achieving a high state of health and function within the body
Not sure yet
Section 6: Acknowledgements
To set clear expectations, improve communication and help you get the best results, please read each statement and initial your agreement.
I instruct the chiropractor to deliver the care that, in her professional judgment, can best help me in my restoration of my health. I also understand that the chiropractic care offered in this practice is based on the best available evidence and designed to reduce or correct vertebral subluxation. Chiropractic is a separate and distinct healing art from medicine, and does not proclaim to cure any named disease or entity.
Initials:
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I may request a copy of the Privacy Policy and understand it describes how my personal health information is protected.
Initials:
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I grant permission to be called to confirm or reschedule an appointment and to be sent occasional cards, letters, emails or health information to me as an extension of my care in this office.
Initials
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I acknowledge that I am responsible for the timely payment of any and all services I receive.
Initials:
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To the best of my ability, the information I have supplied is complete and truthful. I have not misrepresented the presence, severity or cause of my health concern or health issues.
Initials
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