First Name:

Middle Name:

Last Name:

Date of Birth:

What's the best number to call if we have a schedule change or need

to get in touch with you?

Phone Number:

Cell Number:

Work Number:

Street Address:

City:

Zip:

Mailing Address:

City:

Zip:

Occupation:

Please check all that apply to you:

? Recent Fever  

? Prostate Problems  

? Diabetes  

? Menstrual Problems  

? High Blood Pressure  

? Urinary Problems  

? Stroke  

? Abnormal Weight Gain/Loss  

? Corticosteroid Use  

? Marked Morning Pain/Stiffness  

? Taking Birth Control Pills  

? Pain Unrelieved by Position/Rest  

? Dizziness/Fainting  

? Pain at Night  

? Cancer/Tumor  

? Visual Disturbances  

? Osteoporosis  

? Surgeries:

? Epilepsy/Seizures  

? Other:  

? Medications:

Family History:

? Cancer                    

? High Blood Pressure   

? Stroke     

? Diabetes              

? Rheumatoid Arthritis     

? Heart Problems      

I certify, to the best of my knowledge, the above information is complete and accurate.   I understand that I am liable for all charges for services rendered and I agree to notify this doctor immediately whenever I have changes in my healthy condition or health plan coverage in the future.   I understand that my chiropractor or a clinical peer employed may need to contact my physician if my condition needs to be co-managed.   Therefore I give authorization to my chiropractor to contact my physician, if necessary.

Patient Signature:

Date

Please shade symptomatic area ?

Describe your Symptoms:

What caused it/them?

When did your symptoms begin?

Are your symptoms

? Constant?

? Present 25% of the time?

? Present 50% of the time?

? Present 75% of the time?

Do they interfere with your work ability?

  ? <25%    ? 25-50%    ? 50-75%    ?   >75

Do they interfere with daily activity?

  ? <25%    ? 25-50%    ? 50-75%    ? >75

Have you seen another doctor for this?

  ? Yes   ? No   ? Multiple doctors

What did they do?

  ? MRI   ? CT   ? x-rays   ? drugs      

Date and Location?