Chiropractic Health Questionnaire

Date: _________________________

Patient Name: _________________________________________

Birthday: ________________________
Reason for Visit: ___________________________________________________________________________________
Have you been treated before for this problem?
Yes
No
If yes, by
MD
Chiropractor
Physical Therapist
Osteopath
Other________________________
What did they recommend: ___________________________________________________________________________
What caused the problem: ____________________________________________________________________________
When did the symptoms appear:__________ Is this condition getting worse:
Yes
No
Is it constant or does it come and go? ________ Does it interfere with your
Work
Sleep
Daily Routine
Recreation
Activities or movements that are painful to perform
Sitting
Walking
Bending
Lying Down
Other _______________________________________________________________________________________________
Your Occupation (Describe activities- sitting, lifting, etc.) _____________________________________________________________
Have you ever had Chiropractic care for other problems?
Yes
No
When? _____________________________________
Do you take

Muscle Relaxers

Pain Killers

Insulin

Other Medications you are currently taking

Allergies:
Pharmacy Name:
Date of
Last:

Birth Control Pills

Over the Counter Meds

Vitamins/Herbs/Minerals

Phone:

Physical Exam________________

Spinal x-ray_____________________

Blood Test______________

Spinal Exam__________________
Dental x-ray__________________

Chest x-ray_____________________
MRI, CT-Scan, Bone Scan_________

Urine Test______________

CONDITIONS Check if you have or have had in the past.

Aids
Diabetes
Alcoholism
Emphysema
Anemia
Epilepsy
Anorexia
Fractures
Appendicitis
Glaucoma
Arthritis
Goiter
Asthma
Gonorrhea
Bleeding Disorders
Gout
Breast Lump
Heart Disease
Bronchitis
Hepatitis
Bulimia
Hernia
Cancer
Herpes
Cataracts
High Cholesterol
Chemical Dependency
HIV Positive
Chicken Pox
Kidney Disease

Liver Disease
Measles
Migraine Headaches
Miscarriage
Mononucleosis
Multiple Sclerosis
Mumps
Osteoporosis
Pacemaker
Pneumonia
Polio
Prostate Problem
Prosthesis
Psychiatric Care
Rheumatoid Arthritis

Rheumatic Fever
Scarlet Fever
Stroke
Suicide Attempt
Thyroid Problem
Tonsillitis
Tuberculosis
Tumors, Growths
Typhoid Fever
Ulcers
Vaginal Infections
Venereal Disease
Whooping Cough
Surgeries_____________
Other _______________

List any family members who have or have had any of the above conditions: ____________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

General Symptoms Check symptoms you currently have or have had in the past year.
General
Chills
Dental Problems
Depression
Difficulty Sleeping
Dizziness
Fainting
Fever
Forgetfulness
Headaches
Loss of Sleep
Loss of Weight
Nervousness
Numbness
Sweats
Tiredness
Weight Gain
GENITO-URINARY
Blood in Urine
Frequent Urination
Lack of Bladder Control
Painful Urination

GASTROINTESTINAL
Appetite Poor
Bloating
Bowel Changes
Constipation
Diarrhea
Excessive Hunger
Excessive Thirst
Gas
Hemorrhoids
Indigestion
Nausea
Rectal Bleeding
Stomach Pain
Vomiting
Vomiting Blood
Cardiovascular
Chest Pain
High Blood Pressure
Irregular Heart Beat
Low Blood Pressure
Poor Circulation
Rapid Heart Beat
Swelling of Ankles
Varicose Veins

EYE/EAR/NOSE/THROAT
Bleeding Gums
Blurred Vision
Crossed Eyes
Difficulty Swallowing
Double Vision
Earache
Ear Discharge
Hay Fever
Hoarseness
Loss of Hearing
Nose Bleeds
Persistent Cough
Ringing in Ears
Sinus Problems
Vision-Flashes
Vision-Halos
SKIN
Bruise Easily
Hives
Itching
Change of Moles
Rash
Scars
Sore that Wont Heal

MEN Only
Breast Lump
Erection Difficulties
Lump in Testicles
Penis Discharge
Sore on Penis
Other
WOMEN Only
Abnormal Pap Smear
Bleeding Between Periods
Breast Lump
Extreme Menstrual Pain
Hot Flashes
Nipple Discharge
Painful Intercourse
Vaginal Discharge
Other
Date of Last Menstrual
Period_______________
Date of Last
Pap Smear____________
Had a Mammogram
Are Pregnant
Number of Children_________

NECK, BACK, EXTREMITIES Check symptoms you currently have or had in the past year.
Pain From Front to Back
Low Back Feels Out of Place
NECK
Right Left
Neck Pain
Muscle Spasm in Mid-Back
Muscle Spasm in Low Back
Neck Stiffness
ARMS & HANDS
Right Left
HIPS/LEGS/FEET
Right Left
Neck Weakness
Pain in Upper Arm
Pain in Buttocks
Pinched Nerve in Neck
Pain in Elbow
Pain in Hip Joint
Neck Feels Out of Place
Pain in Forearm
Pain Down Leg
Muscle Spasm in Neck
Pain in Hand
Pain in Knee
Grinding/Popping in Neck
Pain in Fingers
Pain in Ankle
Pins & Needles in Arm
Pain in Foot
SHOULDERS
Right Left
Pain in Shoulder Joint
Pins & Needles in Fingers
Weakness of Leg
Pain Across Shoulders
Numbness in Arm
Weakness of Knee
Cant Raise Arm
Numbness in Fingers
Leg Cramps
Above Shoulder Level
Weakness in Arm
OTHER SYMPTOMS
Over Head
Weakness in Hand
Tension in Shoulders
Hands Cold
Pinched Nerve in Shoulder
LOW BACK
Right Left
Low Back Pain
MID-BACK
Right Left
Mid-Back Pain
Low Back Stiffness
Mid-Back Stiffness
Low Back Weakness
Pain Between Shoulder Blades
Pinched Nerve in Low Back
Place an X on the drawing to the right on the areas causing your pain and the letter describing it.
A=ACHE
B=BURNING
PAIN SCALE
Please circle the number that best describes the pain
S=STABBING
N=NUMBNESS
0
1
2
3
4
5
6
7
8
9
10
P=PINS & NEEDLES
NONE
LITTLE
MEDIUM
SEVERE
D=DULL
I certify that the above information is correct to the best of my knowledge.
I will not hold my doctor or any members of his staff responsible for any errors or omissions
That I may have made in the completion of this form.
Patient Signature __________________________________________ Date ____________________
Doctor Signature __________________________________________ Date ____________________