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No Yes If yes, when List other practioners seen for this injury/condition Have you ever been under chiropractic care? No Yes If yes, when Name of party responsible for payment PhoneDo you have health insurance? No Yes Name of company Insurance company name Contact person PhoneClaim # Have you been treated for any conditions in the last year? No Yes If yes, please describe Date of last physical exam MM slash DD slash YYYY Is there a chance that you are pregnant? No Yes Have you had X-rays taken? No Yes If Yes, where? What medications are you taking and for what conditions (Please list dosage and amounts, etc).What vitamins, minerals, or herbs do you currently take? (Please list for what condition, dosage, and frequency).Broken bones? No Yes Briefly explain Been hospitalized? No Yes Briefly explain Been in auto accident? No Yes Briefly explain Had Sprains/Strains? No Yes Briefly explain Been struck unconscious? No Yes Briefly explain Had surgery? No Yes Briefly explain Family members - Present and past health conditions (Example: heart disease, cancer, diabetes, arthritis, etc.)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 What activities aggravate your symptoms?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 EmailThis field is for validation purposes and should be left unchanged.
