Health History Form Please fill-out the form to the best of your ability and then “submit.” We will review all the information at your visit. *** If a question is required but you don’t have an answer, you can respond with “N/A.”*** New Patient History Full Name * How did you hear about us? Date of Birth Home Address (Street, City, State, & Zip Code) Primary Contact Number (Home, Work, or Mobile) Date * When did your symptoms start? * Describe your symptoms, where they are on the body, and how they began: * How often do you experience your symptoms? * Constantly (76-100%) Frequently (51-75%) Occasionally (26-50%) Intermittantly (0-25%) What describes the nature of your symptoms? * Sharp Dull ache Numb Shooting Burning Tingling How are your symptoms changing? * Getting Better Not Changing Getting Worse How bad are your symptoms at their worst? * 0 (None)12345678910 (Unbearable) How bad are your symptoms at their best? * 0 (None)12345678910 (Unbearable) How do your symptoms affect your ability to perform daily activities? * 0 (No Complaints)12 (Mild, Forgotten with Activity)34 (Moderate, Interferes with Activity)56 (Limiting, Prevents full Activity)78 (Intense, Preoccupied with Seeking Relief)910 (Severe, No Activity Possible) What activities make your symptoms worse: * What activities make your symptoms better: * Who have you seen for your symptoms? * No One Other Chiropractor Medical Doctor Physical Therapist Other If you've been seen, when and what was done? What tests have you had for your symptoms and when were they performed? (XRay, MRI, CT, etc) Have you had similar symptoms in the past? * Yes No If you have received treatment in the past for the same or similar symptoms, who did you see? This Office Other Chiropractor Medical Doctor Physical Therapist Other What is your occupation? * What is your current work status? Full-time Part-time Self-Employed Unemployed Off Work Other What do you hope to get from your visit/treatment (select all that apply) * Reduce Symptoms Resume/Increase Activity Explanation of condition/treatment Learn how to take care of this on my own How to prevent this from occurring again What type of regular exercise do you perform * NoneLightModerateStrenuous What is your height? * What is your weight? * For each of the conditions listed below, check any that you are experiencing PRESENTLY: * None Headache Neck Pain Upper Back Pain Mid Back Pain Low Back Pain Shoulder Pain Elbow/Upper Arm Pain Wrist Pain Hand Pain Hip/Upper Leg Pain Knee/Lower Leg Pain Ankle/Foot Pain Jaw Pain Joint Swelling/Stiffness Arthritis Rheumatoid Arthritis General Fatigue Muscular Incoordination Visual Disturbances Dizziness High Blood Pressure Heart Attack Chest Pains Stroke Angina Pacemaker Kidney Stones Kidney Disorders Bladder Inflections Painful Urination Loss of Bladder Control Prostate Problems Abnormal Weight Gain/Loss Loss Appetite Abdominal Pain Ulcer Hepatitis Liver/Gall Bladder Disorders Cancer Tumor Asthma Chronic Sinusitis Diabetes Excessive Thirst Frequent Urination Smoking/Use Tobacco Products Drug/Alcohol Dependence Allergies Depression Systemic-Lupus Epilepsy Dermatitis/Eczema/Rash HIV/AIDS Birth Control Pills Hormonal Replacement Pregnancy For each of the conditions listed below, check any that you have had in the PAST: * None Headache Neck Pain Upper Back Pain Mid Back Pain Low Back Pain Shoulder Pain Elbow/Upper Arm Pain Wrist Pain Hand Pain Hip/Upper Leg Pain Knee/Lower Leg Pain Ankle/Foot Pain Jaw Pain Joint Swelling/Stiffness Arthritis Rheumatoid Arthritis General Fatigue Muscular Incoordination Visual Disturbances Dizziness High Blood Pressure Heart Attack Chest Pains Stroke Angina Pacemaker Kidney Stones Kidney Disorders Bladder Inflections Painful Urination Loss of Bladder Control Prostate Problems Abnormal Weight Gain/Loss Loss Appetite Abdominal Pain Ulcer Hepatitis Liver/Gall Bladder Disorders Cancer Tumor Asthma Chronic Sinusitis Diabetes Excessive Thirst Frequent Urination Smoking/Use Tobacco Products Drug/Alcohol Dependence Allergies Depression Systemic-Lupus Epilepsy Dermatitis/Eczema/Rash HIV/AIDS Birth Control Pills Hormonal Replacement Pregnancy Indicate if an immediate family member has had any of the folowing: Rheumatoid Arthritis Heart Problems Diabetes Cancer Lupus List all prescriptions and over the counter medications, and nutritional/herbal supplements you are taking: * List all surgical procedures you have had and times you have been hospitalized: * Insurance Carrier/Health Plan Name Claims Address (Back of Insurance Card) Subscriber ID If you are human, leave this field blank. Submit Δ Share this:TwitterFacebookLike this:Like Loading...