Today's Date_________________

Full Legal Name ___________________________________________________________

Name you prefer to be called _________________________________________________

Male___   Female___   Date of Birth ___/___/_____    Age ____    SS# ____-____-______

Mailing Address ____________________________________

City ________________  State/Zip __________

Home Phone # __________________    Cell # ________________   

 Work # __________________ Ext.____  Best # to reach you ______________________

Employer ____________________

E-mail Address _______________________________________ 

 Referred By _________________________

Minor ___   Single ___   Married ___   Widowed/Widower ___   Divorced ___

Spouse's Name ____________________   Children?  Y___  N___     How Many? ____________

Your Occupation ____________________   Employeer Address _________________________ 

City ______________________  State/Zip __________           

 Emergency Contact ____________________ Phone # __________________

 

Primary Insured's Name _________________________________________

Relation to You  _______________________________________________

Primary Insured's Date of Birth ____________________________________

 

 Reason for today's visit:  Emergency___  New Injury___  Old Injury___  Chronic Pain___  Wellness___

Circle the level of your pain:   (mild)  - 1   2   3   4   5   6   7   8   9   10 - (intense)

Injury occur during: Work ___  Auto Accident ___  Sports/Play ___  Routine/Home Activity ___

When did injury occur? _________   Where did injury occur? ___________________________

Explain why you are here/what happened:  __________________________________________

__________________________________________________________________________

Is condition getting worse?   Yes____  No____  Constant____  Come and Go____

Has something like this happened in the past?  No ___  Yes____,

 Explain ______________________________

Other physicians seen for this? (MD, DC)  How long ago? _______________________

Ever been treated by a Chiropractor (D.C.)?  No ___  Yes ___   

Where? __________________________ 

Please list all current medications and supplements you are taking.  _________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Ever had or currently have the following, just check those that apply.

___ Heart Attack/Stroke                                 ___ Fainting/Epilepsy/Seizure

___ Artificial Valves                                        ___ Chemotherapy/Radiation

___ Shingles                                                   ___ Frequent Neck Pain

___ High/Low Blood Pressure                         ___ Chronic Sinus Infection

___Fibromyalgia                                              ___ Low Back Problems

___Chronic Fatigue Syndrome                        ___ Glaucoma

___Thyroid Disorder                                        ___ Severe/Frequent Headaches

___Acid Reflux                                                 ___ Asthma/Emphysema

___Ulcers/Colitis                                              ___ Implants/Transplants/Artificial Joints

___Difficulty Breathing                                     ___ Diabetic

___Sleep Difficulties/Insomnia                         ___ Kidney Problems

___Heart Surgery/Pacemaker                          ___ Irritable Bowel/IBS

___Cancer                                                        ___ Cold Hands/Feet

___Alcohol/Drug Abuse                                    ___ Unexplained Weight Gain

___Anxiety/Depression                                     ___ Restless Leg Syndrome

 

List any Surgeries or other diagnoses not listed above. ___________________________________

_______________________________________________________________________________________

Allergies _________________________________       Do you exercise?  No___  Yes___

Smoke: No___  Yes___   How many, how long _______________        Quit ____ How long ago______

Birth Control?  No___  Yes___                 Pregnant?  No___  Yes___         Nursing?  No___  Yes___

Signature:_______________________________________________     Date:____________________

Print out, fill out and fax back to (901) 767-8861 or just bring it with you to your appointment