Jeffrey M.

Cooke, DC
77 East Wilson Bridge Road, Suite 104 Worthington, Ohio 43085
246 Main Street, Suite 6 Cornwall, NY 12518
845-500-1410; drjcooke@aol.com

Welcome to our office! Please complete this questionnaire to help us better help you.

Name_______________________________________________ Today's Date __________________

Birth Date_______ ______________ Age_______ Gender _________________ Single ____
Married/Partner's name____________________________ Widowed ____ Divorced_______
Children/ages______________________________________ ____________________________
Address______________________________________________________ Zip code ____________
Phone: home ______________________ Work __________________ Cell ____________________
e-mail ___________________________________________________
Driver's License No. ________________________________________ State __________________
Reason for visit (be specific)__________________________________________________________
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How did this condition start?________________________________________________________
_____________________________________________________Was onset: gradual ____
sudden ____ Have you had this before? Y __ N __ Is it getting worse? Y __ N __ Any self
care? (describe)_____________________________________________________________________
_________________________________________________________ Has it helped? Y___ N____
What makes your condition better?___________________________________________________
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What makes it worse? _____________________________________________________________
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Have you seen other doctors for this?(list)______________________________________________
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For how long?________________________ Describe treatments___________________________
_____________________________________________________ Did they help? Y ___ N ____
Have x-rays been taken? Y__ N__ Other diagnostic work?______________________________
_____________________________________________Where?_______________________________
__________________________Results/Diagnosis_________________________________________
Have you had chiropractic care before? Y ___ N ___ Where?_____________________________
_______________________________________________________________ For what?_________
__________________________________________________________Did it help? Y ___ N___
May we contact them? Y __ N __
Have you lost any work time from this? If so, state last day worked______________________
Does going to a new doctor make you nervous or apprehensive? Y ___ N ___
List all health issues you see a doctor for ______________________________________________
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List all your medications (including over the counter and aspirin), the dosage and how long
on each ___________________________________________________________________________
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List any allergies you have (foods, drugs, etc) __________________________________________
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List all your illnesses/injuries/surgeries (including cosmetic)/accidents. Include dates
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Do you use: Alcohol? _______ Tobacco? _______ Stimulants? _________ Artificial sweeteners?
______If yes, how much/many of each per day?_________________________________________
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Current health status__________________Physical condition: excellent __ good __ fair __
poor __ Exercise frequency _________________________________________________________
Hobbies/Sports and how often you do them___________________________________________
___________________________________________________________________________________
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Employer/job____________________________________Address___________________________
Describe job_____________________________________________________ Do you like it?____
____________ Computer use: _____hours per week Break frequency _________ Is your work
area comfortable Y __ N __ Stress level at: work ________________________________ home
_________________________________________
How often do you skip meals?______________________Which ones? ______________________
Diet drinks/day ______ Sugary/junk foods/day ____________ Glasses of water/day _____
Coffee/tea/day ________ Fruits/day ___________ Vegetables/day ______________
Do you follow a dietary program (describe type) ____________________________________ __
Do you take: vitamins, herbs/botanicals, homeopathics, etc. (list) ______________________ __
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Do you have pets? (list)______________________________________________________________
Ethnic background: _____________________________________ I prefer not to answer ________
How did you hear about us? _____________________________________________ Is anyone in
your family a patient with us?________________________________________________________
Family Physician's name and address_________________________________________________
________________________________________May we send them a report about this? Y__ N__

Is this a worker's comp claim? Y__ N__ Personal Injury Y __ N__ Private Insurance Y __N ___
Medicare Y ___ N ___ If yes, please ask for additional medicare forms.

Give dates and places, as best you can, for any of the following procedures you have had:
Blood tests ______________________________ Urinalysis ________________________________
MRI ____________________________________ CAT scan ________________________________
Radiation Treatment ________________________ Chemotherapy__________________________
Ultrasound ________________________________ X ray exams_____________________________
Other special exams_________________________________________________________________
List where they were taken___________________________________________________________
___________________________________________________________________________________
Do we have your permission to contact the ordering doctor/facility to get copies of your
results? Y __ N ___
Do you have a pacemaker or other implantable electronic device? If so, what?______________
______________________ Do you wear dentures? Y ___ N ___
Date of last menstural period, if applicable ___________________________________
Do you have any reason to think you may be pregnant? Y ___ N ___
Do you have any other health problems not listed above? If so, what?____________________
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Have you been treated by a physician for anything in the past year? If so, what?
___________________________________________________________________________________
Do you gain or lose weight easily? Y___ N____ Have you gained or lost weight the past
year? If so, how much? __________________________

For the symptoms listed below, please denote with 'Y' if you have them now, 'O' if you have
them occasionally, and leave blank if it's not an issue.
Headaches _____ Stiff neck _____
Neck pain/ _____numbness, tingling _____/ weakness _______/ aching _______
Mid back pain _____/ numbness, tingling _____/ weakness _______/ aching _______
Low back pain _____/ numbness, tingling _____/ weakness _____/ aching __________
Hip joint pain _____/ numbness, tingling _____/ weakness _____/ aching ___________
Leg pain _____/ numbness, tingling _____/ weakness ______/ aching __________
Knee pain _____/ numbness, tingling _____/ weakness _______________/ aching _______
Ankle pain _____/ numbness, tingling _____/ weakness _____________/ aching _____
Foot pain _____/ numbness, tingling _____/ weakness __________/ coldness _________
Shoulder joint pain_ ____/numbness, tingling _____/ weakness __________/ aching ______
Arm pain _____/ numbness, tingling _____/ weakness ______/ aching _______
Elbow pain _____/ numbness, tingling _____/ weakness _____/ aching _______
Wrist pain _____/ numbness, tingling _____/ weakness _____/ aching ________
Hand/finger pain ____/ numbness, tingling _____/ weakness _____/ coldness ________
Insomnia _______
Irritability _______
Nervousness ______
Dizziness ________
Loss of balance _______
Chest pains __________
Shortness of breath ________
High blood pressure ________
Fatigue ________
Depression _________
Memory loss ________
Difficulty concentrating ________
Vision changes __________
Hearing changes ___________
Changes in smell _________
Ringing in ears _____
Other ear noses _____

Constipation _______ Diarrhea ________ Indigestion __________ Acid stomach _____

Acid reflux _______ Hard to digest fatty food __________ Frequent burping _________
Menstrual cramping ______ /pain _____ /discomfort _______
Difficult urination __________ Frequent urination ___________ Do you wake up at night to
urinate? If so, how often? _____________________

The following questions are 'yes' or 'no' with space at the end for any additional details you
want to provide.
Do you currently have cancer? Yes ___ No ___
If yes, are you undergoing treatment? Yes ___ No ____
Have you had cancer in the past? Yes ___ No ___
Have you noticed any changes in warts or moles you have? Yes ___ No ____
Do you have a sore/sores that don't heal? Yes ___ No ____
Do you have any unusual bleeding or discharge? Yes ____ No ____
Do you have any lumps or thickening in your breasts? Yes ____ No ____
Do you have any lumps or thickening in your groin or armpits? Yes ____ No ____
Has your voice become hoarse or do you have trouble swallowing? Yes ____ No ____
Do you have a nagging/chronic cough? Yes ____ No ____
Are you coughing up blood? Yes ____ No ____
Do you have headaches for hours or days? Yes ____ No ____
Do you have night sweats? Yes ____ No ____
Do you have chest pain? Yes ____ No ____
Do you have slurred speech? Yes ____ No ____
Do you have double vision? Yes ____ No ____
Do you take birth control pills? Yes ____ No ____
Do you have a family history of stroke? Yes ____ No ____
Have you been losing weight without trying? Yes ____ No ____
Have you noticed blood in your stool? Yes ____ No ____
Have you had or are you having a loss of bowel or bladder control? Yes ____ No ____
Does pain ever wake you up from a sound sleep? Yes ____ No ____
Have you had a change in appetite lately? Yes ____ No ____

FAMILY HISTORY
If either parent had any of the following, put 'M' for mother, 'F' for father, or 'B' for both.
High blood pressure ___________ Heart attack ___________ Stroke ____________
Atrial fibrillation _____________ Circulatory problems __________
COPD/emphysema ____________ Asthma _______________ Cancer ___________________
Macular degeneration ________________ Thyroid disease _______________________
Kidney disease _______________ Liver disease _________________
Depression _______________ Anxiety ________________ Schizophrenia _______________
Arthritis _________________ Osteoporosis _________________ Diabetes ________________

Please add anything else you think relevant

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I understand and agree that health and accident insurance policies are an agreement between
the insurance carrier and myself, and that all goods and services rendered to me are charged
directly to me and that I am personally responsible for payment. I also understand that if I
suspend or terminate my care and treatment, any fees for professional services rendered me
will be immediately due and payable.

Patient Signature __________________________________________________________________

Social Security Number ____________________________ Date __________________________