Patient Data and Current Medical History Date MM slash DD slash YYYY Patient Name First Middle Last Suffix Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home PhoneCell PhoneWork PhoneWould you prefer appointment reminders via text? Yes No Preferred Contact NumerHome PhoneCell PhoneWork PhoneSelect your preferred contact phoneEmail Date of Birth MM slash DD slash YYYY AgeSexMaleFemalePlease provide sex assigned at birth.Referred by Employer Occupation Emergency Contact Name First Last Relationship PhonePatient Medical HistoryWhat is your complaint How long have you had this problem Have you had any previous care or seen any other provider(s) for this problem/Are you seeing any doctors? What are you doing for it now? Is it working? Have you noticed any changes in your daily activities due to the problem or pain? (Dressing, Cooking, etc.) Are there any other related or unrelated systems? Overall Stress Level (0=Low / 10=High) 0 1 2 3 4 5 6 7 8 9 10 What is your sleeping habit? On Back On Side On Stomach When was the last time you really felt good? PATIENT HISTORY / REVIEW OF SYMPTOMSPlease tell us if YOU or a member of YOUR IMMEDIATE FAMILY have had any of the following.SYMPTOMSYouFAMILY MEMBERBack Pain / Leg PainBack Pain / Leg Pain(You) Yes No Back Pain / Leg Pain(Family Member) Yes No Neck Pain / Arm PainNeck Pain / Arm Pain(You) Yes No Neck Pain / Arm Pain(Family Member) Yes No CancerCancer(You) Yes No Cancer(Family Member) Yes No DiabetesDiabetes(You) Yes No Diabetes(Family Member) Yes No Neurological Disease / Headaches / SeizuresNeurological Disease / Headaches / Seizures(You) Yes No Neurological Disease / Headaches / Seizures(Family Member) Yes No Heart / Circulatory ProblemsHeart / Circulatory Problems(You) Yes No Heart / Circulatory Problems(Family Member) Yes No High Blood PressureHigh Blood Pressure(You) Yes No High Blood Pressure(Family Member) Yes No Stomach or Bowel ProblemsStomach or Bowel Problems(You) Yes No Stomach or Bowel Problems(Family Member) Yes No Broken BonesBroken Bones(You) Yes No Broken Bones(Family Member) Yes No Skin DiseaseSkin Disease(You) Yes No Skin Disease(Family Member) Yes No Prostate Disease / Hormone TherapyProstate Disease / Hormone Therapy(You) Yes No Prostate Disease / Hormone Therapy(Family Member) Yes No Depression, Anxiety, etc.Depression, Anxiety, etc.(You) Yes No Depression, Anxiety, etc.(Family Member) Yes No Painful or Irregular Menstrual CyclesPainful or Irregular Menstrual Cycles(You) Yes No Painful or Irregular Menstrual Cycles(Family Member) Yes No TendonitisTendonitis(You) Yes No Tendonitis(Family Member) Yes No Exercise on a Regular BasisExercise on a Regular Basis(You) Yes No Exercise on a Regular Basis(Family Member) Yes No Motor Vehicle Accident or Other InjuriesMotor Vehicle Accident or Other Injuries(You) Yes No Motor Vehicle Accident or Other Injuries(Family Member) Yes No Alcohol / Nicotine UseAlcohol / Nicotine Use(You) Yes No Alcohol / Nicotine Use(Family Member) Yes No Allergies / Upper Respiratory Infection / Flu / CoughAllergies / Upper Respiratory Infection / Flu / Cough(You) Yes No Allergies / Upper Respiratory Infection / Flu / Cough(Family Member) Yes No SurgeriesSurgeries(You) Yes No Surgeries(Family Member) Yes No Chiropractic Treatment BeforeChiropractic Treatment Before(You) Yes No Chiropractic Treatment Before(Family Member) Yes No Unintended Weight Gain / LossUnintended Weight Gain / Loss(You) Yes No Unintended Weight Gain / Loss(Family Member) Yes No Recent International TravelRecent International Travel(You) Yes No Recent International Travel(Family Member) Yes No LIST OF MEDICATIONS Add Remove
