Full Name *

Mobile Number *

Email *

Date of Birth *

Gender *

Male
Female
Other
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Address *

City *

State *

Postal code *

Primary goals for seeking chiropractic care *

Occupation *

Employer *

What is your work schedule?

Have you ever received chiropractic care? *

Yes
No
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If yes, when? *

Do you have any numbness or tingling in your body? If so, where? *

History of present illness / chief complaint *

Location of complaint *

Please select the quality of the complaint / pain *

Dull
Aching
Sharp
Shooting
Burning
Throbbing
Deep
Nagging
Other
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If you selected other, please specify *

Does this complaint / pain radiate or travel (shoot) to any areas of your body? If so, where? *

Previous injuries / trauma *

Grade intensity / severity *

0 (no complaint / pain)
1
2
3
4
5
6
7
8
9
10 (worst possible complaint / pain imaginable)
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How frequent is complaint present? How long does it last? *

Aggravating factors? *

Alleviating factors? *

Previous interventions, treatments, medications, surgery, or care you've received for your complaint *

Previous illnesses you've had in your life *

Have you ever broken any bones? If so, which? *

Please list any allergies. If none, write N/A *

Please list any medications and reason for taking. If none, write N/A *

Please list any surgeries and dates when they were performed. If none, write N/A *

Please list all pregnancies and outcomes (e.g. vaginal delivery, c-section, miscarriage, or abortion). If none, write N/A *

What was the start date of your last menstrual period? *

Please list all recreational activities *

Lifestyle habits (check all that apply) *

Drink alcohol

Smoke tobacco

Drug use

None of the above

Please describe what a current average day looks like *

I have read the above information and certify it to be true and correct to the best of my knowledge, and hereby authorize this office of Chiropractic to provide me with chiropractic care, in accordance with this state's statutes.

Signature of patient or guardian *

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