Has this condition occurred before? _____Y _____N
Other treatment sought for this condition? _____Y _____N
Is condition _____Job related _____Auto Accident _____Home Injury _____Fall
Other: _____ Type of Treatment: ____________________________________________
Over the counter drugs/Vitamins that you currently take? __________________________
_________________________________________________________________________
Current Prescriptions: Insulin/Heart/antibiotics, etc: _______________________________
_________________________________________________________________________
Previous Chiropractic Treatment? Y/N Chiropractor's name and last date of treatment:
__________________________________________________________________________
PAST HEALTH HISTORY
Major Surgery/Operations: ____________________________________________________
__________________________________________________________________________
Major accidents or falls: describe and date: _______________________________________
__________________________________________________________________________
Sprain/Strain: describe and date: ________________________________________________
__________________________________________________________________________
Hospitalization: describe and date: _______________________________________________
___________________________________________________________________________
Pain Scale: Please circle one
(no pain) 0 1 2 3 4 5 6 7 8 9 10 (intense pain)
System Review: check any symptoms that you may have
_____headaches _____allergies _____poor appetite _____dizziness _____nausea
_____constipation _____fatugue _____vomitting _____diarrhea _____numbness
_____heartburn _____ulcer _____weak muscles _____high blood pressure
_____chronic cough _____stiff/sore neck _____stroke _____difficult breathing
_____pain in shoulders _____ankle swelling _____painful urination _____low back pain
_____short of breath _____frequent urination _____leg/arm pain _____carpal tunnel
Have you had any of the following diseases:
_____pheumonia _____anemia _____heart disease _____polio _____influenza
_____chicken pox _____tuberculosis _____diabetes _____pleurisy _____cancer
_____arthritis _____whoopoing cough _____mumps _____thyroid _____rheumatic fever
Lifestyle: _____coffee _____soda _____alcohol _____smoking
Exercise routine: _______________________________ Do you sleep well? Y/N
What position do you sleep in _____________________
Any family diseases:
Mother__________________________ Father ___________________________
Sisters __________________________ Brothers __________________________
