LifeSource Family Chiropractic - Chiropractor In Wesley Chapel; FL; USA

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Patient Data

First Name *

Last Name *

Date *

Email *

Address *

City *

State *

Zip *

Telephone (Home) *

Telephone (Cell)

Telephone (Work)

Referred By *

Age

Birthdate (MMDDYYYY) *

Gender *

Social Security # *

Number of Children

Employment Status *

Occupation

Employer

Employer Address

Employer City

Employer State

Employer Zip

Marital Status

Spouse's Name

Spouse's Occupation

Spouse's Employer

Emergency Contact

Phone

Have you ever been under chiropractic care?

NoYes

If yes, when was your last visit?

Chief Complaint

What is Your Primary Complaint? *

How long have you been experiencing this problem?

On a scale of 1-10, how severe is it at its worst?

What percent of your awake time do you experience your main complaint?

What makes it feel better?

What makes it feel worse?

When do you notice it most?

MorningAfternoonEvening

I Have...

Been HospitalizedBeen Seen By Another ChiropractorBeen Seen By Another DoctorNever Received Treatment for this Problem

Medical History

Have you ever had surgery?

NoYes

If yes, please specify

Date oflast menstrual period

Is there a chance that you are pregnant?

NoYes

Have you had X-rays taken?

NoYes

If yes, where?

What medications are you taking and for what conditions? (Please list dosage and amounts, etc.)

What vitamins, minerals, or herbs do you currently take? (Please list for what condition, dosage, and frequency.)

List any allergies you have.

List any recent falls or acciedents.

Broken Bones?

NoYes

If yes, please explain.

Habits

Alcohol

NoneDailyOnce a weekOnce a month

Coffee

NoneSeveral cups a dayOne cup per dayEvery now and then

Tobacco

NoneLightModerateHeavy

Drugs

NoneLightModerateHeavy

Exercise

NoneEveryday2-3 times per weekEvery now and then

Sleep

0-3 hours per night4-6 hours per night7-9 hours per night10+ hours per night

Have you ever suffered from:

....

ADD/ADHDAlcoholismAllergies/SinusAnemiaArthritisAsthmaBack Pain-Upper/MidBack Pain-LowerBed WettingBruise EasilyCancerChest PainCold ExtremitiesColon TroubleCongenital DiseaseConstipation/DiarrheaCoughing BloodCrampsDepressionDiabetesDigestion ProblemsDizzinessDrug AddictionEar InfectionEar RingingEating ProblemsEpilepsyEye Pain or DifficultiesFaintingFatigueFoot TroubleFrequent UrinationGall BladderHeadachesHeart AttackHeartburnHigh/Low Blood PressureHip PainHIV PositiveIrregular Heart BeatKidney InfectionKidney StonesLearning DisabilityLoss of memoryLoss of balanceLoss of smellLoss of tasteMenopausal ProblemsMenstrual ProblemsMigrainesMood ChangesNeck Pain or StiffnessNumbness/TinglingPacemakerPain with Coughing/SneezingPMSPolioProstate TroubleSciaticaShortness of breathShoulder PainSleep problems or InsomniaSpinal CurvaturesStrokeSwollen/Painful JointsThyroid ConditionTMJ PainTremorsTrouble ConcentratingTuberculosisTumorsUlcersVaricose VeinsVenereal DiseaseOther

Other

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