Print form below, fill out and bring with you to your office visit:

PERSONAL HISTORY

Name:_______________________________ City:________________________________ Home Phone:_________________________ Social Security #:______________________ Business Employer:____________________ Business Phone:_______________________ Name Of Spouse:______________________ Spouse's Employer:____________________ Type Of Work:________________________ Referred To This Office By:______________		Address:_____________________________ State:_________Zip:____________________ Birth Date:____________________________ Sex: M F Age:___________________ Driver's License Number:________________ Married Single Widowed Divorced Separated Type Of Work:_________________________ Spouse's Social Security #:_______________ Business Phone:________________________
Names And Ages Of Children: ___________________________________________________________ Name And Number Of Emergency Contact: ___________________________________________________________ Payment Option: Cash Woker's Comp Auto Insurance Medicare Insurance Provider: ________________________________ Policy No.:_______________________________________ E-mail:_______________________________________

CURRENT HEALTH CONDITION

Purpose of this appointment:_________________________________________________________ Have you seen other doctors for this condition: Yes No Who?_________________________ Type of treatment:____________________________ Results:______________________________ When did condition begin?________________ Has this condition occurred before?: Yes No Is Condition: Job Related Auto Accident Home InjuryFall Other:___________________________________ Date Of Accident:__________________________ Time Of Accident:__________________________ If work related, have you made a report of the accident to your employer? Yes No Please list all medications you are currently taking, please include all over the counter medications: _________________________________________________________________________________ Do you wear a shoe lift? Yes No Do you suffer from any condition other than that for which you are consulting us? _________________________________________________________________________________

PAST HEALTH HISTORY

Please Check and Describe: Major Surgery/Operations: Appendectomy Tonsillectomy Gall Bladder Hernia Back Surgery Broken Bones Other:__________________________________________ Major Accidents or Falls: ___________________________________________________________________________________ Hospitalizations (Other Than Above): ___________________________________________________________________________________ Previous Chiropractic Care: None Doctor's name & approximate date of last visit: ___________________________________________________________________________________ Check Any Of The Following Diseases You Have Had: Intake: Pneumonia Rhematic Fever Polio Tuberculosis Whooping Cough Anemia Measles Cramps Small Pox Chicken Pox Diabetes Cancer Heart Disease Thyroid Influenza Pleurisy Arthritis Epilepsy Mental Disorders Lumbargo Eczema Coffee Tea Alcohol Cigarettes White Sugar Have you been tested HIV Positive?___________________ Check Any Of The Following You Have Had In The Past 6 Months: Musculo-Skeletal Genito-Urinary Low Back Pain Pain Between Shoulders Neck Pain Arm Pain Joint Pain/Stiffness Walking Problems Difficulty Chewing General Stiffness Gas/Bloating After Meals Heartburn Black/Bloody Stool Colitis Bladder Trouble Painful/Excessive Urination Discolored Urine Females Only When was your last period? _________________________ Are you pregnant? Yes No Not Sure Nervous System C-V-R Nervous Numbness Paralysis Dizziness Forgetfulness Confusion/Depression Fainting Convulsions Cold-Tingling Extremities Stress Chest Pain Short Breath Blood Pressure Problems Irregular Heartbeat Heart Problems Lung Problems/Congestion Varicose Veins Ankle Swelling Stroke General EENT Fatigue Allergies Loss of Sleep Fever Headaches Vision Problems Dental Problems Sore Throat Ear Aches Hearing Difficulty Stuffed Nose Gastro-Intestinal Male/Female Family History Poor/Excessive Appetite Excessive Thirst Frequent Nausea Vomiting Diarrhea Constipation Hemorrhoids Liver Problems Gall Bladder Problems Weight Trouble Menstrual Cramps Menstrual Irregularity Vaginal Pain/Infection Breast Pain/Lumps Prostate/Sexual Dysfunction Other Problems _______________________ _______________________ _______________________ The following family members have a same or similar problem as I do: Mother Father Brother Sister Spouse Child