Patient Name

Today's Date

Date of Birth

Your Age

Your Height

Your Weight

Your Gender

Address

City

State

Zip Code

Cell Phone

Home Phone

Work Phone

Email Address

Referred By What Doctor?

Your Primary Physician

Your Primary Physician's Phone Number

Your Primary Physician's Phone Fax

Emergency Contact

Emergency Contact Phone Number

Have you ever used: Have you ever used: Chiropractic Treatment Chinese Herbal Medicine Acupuncture Homeopathy

If yes, for which conditions?

If no, would you like to hear about options for your condition? (Yes/No)

How severe is #3? Mild/Moderate/Severe

#1 Top Ranking Health Concern to be addressed

Year #1 Health Concern Began

How severe is #1? Mild/Moderate/Severe

How often does #1 Health Problem occure?

Describe #1 Health Condition at it's worst:

#2 Health Concern to be addressed

Year #2 Health Concern Began

How severe is #2? Mild/Moderate/Severe

How often does #2 Health Problem occure?

Describe #2 Health Condition at it's worst:

#3 Health Concern to be addressed

Year #3 Health Concern Began

How often does #3 Health Problem occure?

Describe #3 Health Condition at it's worst:

#4 Health Concern to be addressed

Year #4 Health Concern Began

How severe is #4? Mild/Moderate/Severe

How often does #4 Health Problem occure?

Describe #4 Health Condition at it's worst:

Other Complaints or Conditions:

Diagnosed Medical Conditions:

Cause of Health Conditions: Cause of Health Conditions: Injury Auto Accident Personal Injury Other

Describe other cause:

Has the accident been reported? Has the accident been reported? Yes No

Who was the accident reported to? Who was the accident reported to? Employer Auto Carrier Other (reported to)

Who else was the accident reported to?

Are you now or have you ever been disabled? Are you now or have you ever been disabled? Yes (Disabled) No (Not Disabled)

If Yes, the Date and Cause of your disability:

Have you ever retained an attorney? Have you ever retained an attorney? Yes (I have retained an Attorney) No (I have not retained an Attorney)

Your retained Attorney's Name and Phone number

List pain symptom or discomfort #1 and location in order of severity.

What month and year did pain or discomfort symptom #1 begin?

What month and year was your last episode for pain or discomfort symptom #1?

Description of pain or discomfort symptom #1? Description of pain or discomfort symptom #1? Numbness Tingling Burning Pain Soreness Ache Stabbing Stiffness Scars

Frequency of pain or discomfort symptom #1? Frequency of pain or discomfort symptom #1? 20% of the time 40% of the time 60% of the time 80% of the time 100% of the time

Severity of pain or discomfort symptom #1? Severity of pain or discomfort symptom #1? Annoying Impairment to Activity Need Medication Impairment with Medication Severe (Need Hospitalization)

Initial cause of pain or discomfort symptom #1?

Is pain or discomfort symptom #1 getting worse? Is pain or discomfort symptom #1 getting worse? Yes No

Does pain or discomfort symptom #1 affect other areas of your body? Does pain or discomfort symptom #1 affect other areas of your body? Yes No

If yes, explain (pain or discomfort symptom #1 affect other areas of your body?)

List pain or discomfort symptom #2 and location in order of severity.

What month and year did pain or discomfort symptom #2 begin?

What month and year was your last episode for pain or discomfort symptom #2?

Description of pain or discomfort symptom #2? Description of pain or discomfort symptom #2? Numbness Tingling Burning Pain Soreness Ache Stabbing Stiffness Scars

Frequency of pain or discomfort symptom #2? Frequency of pain or discomfort symptom #2? 20% of the time 40% of the time 60% of the time 80% of the time 100% of the time

Severity of pain or discomfort symptom #2? Severity of pain or discomfort symptom #2? Annoying Impairment to Activity Need Medication Impairment with Medication Severe (Need Hospitalization)

Initial cause of pain or discomfort symptom #2?

Is pain or discomfort symptom #2 getting worse? Is pain or discomfort symptom #2 getting worse? Yes No

Does pain or discomfort symptom #2 affect other areas of your body? Does pain or discomfort symptom #2 affect other areas of your body? Yes No

If yes, explain (pain or discomfort symptom #2 affect other areas of your body?)

List pain or discomfort symptom #3 and location in order of severity.

What month and year did pain or discomfort symptom #3 begin?

What month and year was your last episode for pain or discomfort symptom #3?

Description of pain or discomfort symptom #3? Description of pain or discomfort symptom #3? Numbness Tingling Burning Pain Soreness Ache Stabbing Stiffness Scars

Frequency of pain or discomfort symptom #3? Frequency of pain or discomfort symptom #3? 20% of the time 40% of the time 60% of the time 80% of the time 100% of the time

Severity of pain or discomfort symptom #3? Severity of pain or discomfort symptom #3? Annoying Impairment to Activity Need Medication Impairment with Medication Severe (Need Hospitalization)

Initial cause of pain or discomfort symptom #3?

Is pain or discomfort symptom #3 getting worse? Is pain or discomfort symptom #3 getting worse? Yes No

Does pain or discomfort symptom #3 affect other areas of your body? Does pain or discomfort symptom #3 affect other areas of your body? Yes No

If yes, explain (pain or discomfort symptom #3 affect other areas of your body?)

Do you have, or have you ever had any of the following? Do you have, or have you ever had any of the following? Osteoarthritis Bone Spurs Non-union Fracture Ganglion or Baker’s Cyst Bulging Disc Tendonitis Avascular Necrosis Cartilage injury-(Meniscus Tear, Chondromalacia Patellar Syndrome) Herniated Disc Joint Separations Post-herpetic neuralgia DDD Bursitis Intercostal Neuralgia Stenosis Sprains Morton’s Neuroma

Does the condition interfere with (please check): Does the condition interfere with (please check): Work Sleep Other:

Please describe the Other interference:

Without treatment, how would it affect your quality of life?

What seems to make the condition better?

What seems to make it worse?

What treatments have you tried?

If you are currently under the care of a health care practitioner for any conditions or injuries, please provide their name:

If you are currently under the care of a health care practitioner for any conditions or injuries, please provide their phone:

If you are currently under the care of a health care practitioner for any conditions or injuries, please provide their email:

If you are currently under the care of a health care practitioner for any conditions or injuries, please provide a description of treatment:

Please list any current therapies:

My Appetite is: My Appetite is: Low Moderate High

I have a thirst for water: I have a thirst for water: Yes No

How many 8 ounce glasses of water per day do you drink?

Do you drink Coffee? Do you drink Coffee? Yes No

How many cups of coffee per day do you drink?

Do you drink Soda? Do you drink Soda? Yes No

Do you use Artificial Sweeteners? Do you use Artificial Sweeteners? Yes No

How many cans/glasses of soda per day do you drink?

Do you have cravings for sugar? Do you have cravings for sugar? Yes No

Do you have cravings for salty foods? Do you have cravings for salty foods? Yes No

On a daily basis, what is your stress level? On a daily basis, what is your stress level? Low Moderate High

Do you drink Alcohol? Do you drink Alcohol? Yes No

If yes, how many glasses per day do you drink alcohol? If not daily, specify how often.

Do you smoke cigarrettes? Do you smoke cigarrettes? Yes No

If yes, how many cigarrettes per day do you smoke?

Do you consume Marijuana? Do you consume Marijuana? Yes No

If Yes, how many times a day do you consume Marijuana?

List other drugs you use and frequency of use:

List any Occupational Hazards:

What is your exercise level? What is your exercise level? None Light Moderate Active Very Active Elite Athlete

Type of Exercise:

Frequency of Exercise:

List vitamins or supplements taken in the last 2 months:

List prescribed and over-the-counter pharmaceutical medication taken in the last 2 months: List prescribed and over-the-counter pharmaceutical medication taken in the last 2 months: TUMS Zantac Other over the counter:

Describe OTHER prescribed and over-the-counter pharmaceutical medication taken in the last 2 months:

Proton Pump Inhibitors (please check): Proton Pump Inhibitors (please check): Prilosec Pepcid Prevacid Other Proton Pump Inhibitors

Describe OTHER Proton Pump Inhibitors:

List other medications you take:

Please Describe Your Health History, check all below that apply:

With whom do you live with? (Include roommates, friends, partner, spouse, children, parents, relatives and pets)

Age of #1 person you live with

What is the Relationship of #1 person you live with?

#2 person whom do you live with? (Include roommates, friends, partner, spouse, children, parents, relatives and pets)

Age of #2 person you live with

What is the Relationship of #2 person you live with?

#3 person whom do you live with? (Include roommates, friends, partner, spouse, children, parents, relatives and pets)

Age of #3 person you live with

What is the Relationship of #3 person you live with?

#4 person whom do you live with? (Include roommates, friends, partner, spouse, children, parents, relatives and pets)

Age of #4 person you live with

What is the Relationship of #4 person you live with?

What prior experiences have you had with alternative or complementary medicine?

What are the major stressors in your life?

Source of comfort and connection:

What do you do to relax or relieve stress?

What interests or hobbies do you have?

What is your current occupation?

What was your past occupation(s)?

Spiritual beliefs/religious affiliations, past and present:

What physical activities do you participate in and how often?

Your Energy Level (1 lowest and 10 highest)

Describe your sleep pattern:

How many meals do you generally eat per day?

Do you skip meals?

How many servings of fruit per day? (Svg: 1 small fruit, 1⁄2 C canned/chopped fruit, 1⁄4 C dried fruit)

How many servings of vegetables do you consume each day? (Svg: 1⁄2 C raw/cooked, 1 C leafy veg.)

Are you currently on a special diet? Food allergies? Foods you avoid? Vegetarian?

What are your sources of protein?

What type of oil or spreads do you add to your food?

What and how much do you drink on a typical day? (i.e.: water, caffeine drinks, soda, etc.)

How would you describe your relationship with food?

How often do you eat out?

Who prepares the meals at home?

Do you currently smoke Cigaretts? (Y/N/Never Used)

How many years have you smoked Cigarettes

Amount of Cigarettes you smoke per week

Do you currently smoke Cigar/Pipe? (Y/N/Never Used)

How many years have you smoked Cigars/Pipe

Amount of Cigars-Pipes you smoke per week

Do you currently chew Tobacoo? (Y/N/Never Used)

How many years have you chewed Tobacco?

Amount of Chewing Tobacco you use per week

Do you use recreatioal drugs? (Y/N/Never used, list king and amount used per day/week and years used)

Do you drink alcohol? (Y/N/Never used, list kind and amount used per day/week and years used)

Have you ever had to cut down on your drinking? (Yes/No, explain)

Do you get annoyed when someone asks about your drinking? (Yes/No, explain)

Do you ever feel guilty about your drinking? (Yes/No, explain)

Do you ever make excuses for drinking or for your behavior while drinking? (Yes/No, explain)

Please check the following conditions that apply to you and give details that apply:

Medical History Medical History Alcoholism or Substance Abuse Anemia (Sickle Cell or Other) Arthritis/Joint Disease Blood Clots/Phlebitis Cancer Digestive (Ulcerative Colitis, Crohns, etc.) Diabetes Easy Bleeding Frequent Sinusitis Hay Fever, Allergy, Eczema Heart Murmur Gall Bladder Trouble Headaches (Migraines, etc.) Heart Attack, Heart Disease, Heart Failure High Blood Pressure High Cholesterol History of Infertility Kidney Infection/ Stones Liver Disease, Hepatitis, etc. Lung Disease (Asthma, COPD, etc.) Mental Trouble/ Depression/Anxiety, etc. Pneumonia Radiation Treatments Rheumatic Fever Seizures, Epilepsy Serious Injury or Accident (explain below) Sexually Transmitted Disease (Chlamydia, Warts, Herpes, etc. Skin Disease Stroke Thyroid Disease Tuberculosis (TB) Urinary Difficulties (Incontinence, Infections, etc.) Vision Problems

Please give details of types of cancer, digestive issues, headaches, lung disease, mental issues, seisures/epilespsy, STD's, urinary issues or any other conditions.

Please list any operations/surgical procedures/blood transfusion/major injuries ( Dates):

Immunizations/vaccinations:

WOMEN ONLY - Reproductive History

Age at 1st menstrual period

First day of most recent menstrual period

Usual Flow: (Heavy/Moderate/Lite)

Length of period in days

Number of days between periods

Women Only - Do you have: Women Only - Do you have: Painful Periods Missed Periods Spotting Between Periods Vaginal Bleeding Unusual Discharge/Infection Recurring Vaginal Infections

Date of last Pap

History of abnormal Paps?

Number of Pregnancies

Number of Live Births

Number of Abortions

Number of Miscarriages

Have you experienced complications during pregnancy/delivery/other problems?

Contraceptive History: Please check the method of contraception you are currently using: Contraceptive History: Please check the method of contraception you are currently using: Birth Control Pills Diaphragm/Cap IUD Norplant Condom and/or Foam Suppository Tubal Ligation Hysterectomy Partner with Vasectomy None

Please detail types of birth control pill, diafragm/cap, IUD you are currently using.

If using a diaphragm/cap, what size is it?

If using an IUD, what is the date it was last changed?

How many years have you been using your current type of contraception?

List any other types of contraception used not listed above.

List any problems with current contraception method

WOMEN ONLY - Sexual Preference: WOMEN ONLY - Sexual Preference: Heterosexual Homosexual Bisexual

MEN ONLY - Do you have: MEN ONLY - Do you have: Prostate Problems Sexual Dysfunction Testicular Cancer Vasectomy

MEN ONLY - Sexual Preference: MEN ONLY - Sexual Preference: Heterosexual Homosexual Bisexual

What medications are you taking now? (Include prescription and over-the-counter drugs.) Please list dosage per day, reason for taking and when you started taking it.

What are you allergic to or have you had a "bad reaction" to any medications or other substances?

What vitamins/mineral/herbal supplements are you taking now? Plesae include the brand, dosage per day, reason for taking and when you started taking it.

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