Patient Form

Nature of Injury Automobile Work Other

Have you ever had same condition? No Yes

Have you ever been under chiropractic care? No Yes

Do you have health insurance? No Yes

Have you been treated for any conditions in the last year? No Yes

Is there a chance that you are pregnant? No Yes

Have you had X-rays taken? No Yes

Broken bones? No Yes

Been hospitalized? No Yes

Been in auto accident? No Yes

Had Sprains/Strains? No Yes

Been struck unconscious? No Yes

Had surgery? No Yes

Do you experience pain every day? No Yes

Do your symptoms interfere with daily life? No Yes

Does pain wake you up at night? No Yes

Are your symptoms worse during certain times of the day? No Yes

Do changes in weather affect your symptoms? No Yes

Do you wear orthotics? No Yes

Do you take vitamin supplements? No Yes

Alcohol No Yes

Coffee None Light Moderate Heavy

Tobacco None Light Moderate Heavy

Drugs None Light Moderate Heavy

Exercise None Light Moderate Heavy

Sleep None Light Moderate Heavy

Appetite None Light Moderate Heavy

Soft Drinks None Light Moderate Heavy

Water None Light Moderate Heavy

Salty Foods None Light Moderate Heavy

Sugary Foods None Light Moderate Heavy

Artificial Sweeteners None Light Moderate Heavy

Have you ever suffered from: Alcoholism Allergies Anemia Arteriosclerosis Arthritis Asthma Back Pain Breast Lump Bronchitis Bruise Easily Cancer Chest Pain Cold Extremities Constipation Cramps Depression Diabetes Digestion Problems Dizziness Ears Ring Excessive Menstruation Eye Pain or Difficulties Fatigue Frequent Urination Headache Hemorrhoids High Blood Pressure Hot Flashes Irregular Heart Beat Irregular Cycle Kidney Infection Kidney Stones Loss of memory Loss of balance Loss of smell Loss of taste Lumps In Breast Neck Pain or Stiffness Nervousness Nosebleeds Pacemaker Polio Poor Posture Prostate Trouble Sciatica Sexually Transmitted Infection Shortness of breath Sinus Infection Sleep problems or Insomnia Spinal Curvatures Stroke Swelling of ankles Swollen Joints Thyroid Condition Tuberculosis Ulcers Varicose Veins Other