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PERSONAL HISTORY

Date:____________________________________________ Social Security No.:__________________________________
Name:___________________________________________ Address:___________________________________________
City:____________________________________________ State:_________Zip:_________________________________
Home Phone:_____________________Cell Phone:_____________________Business Phone:_______________________
E- Mail Address:_____________________________________________________________________________________
Birthdate: ___________________________Age:___________Gender:

M

F

TG

Other

Business/Employer:__________________________________ Type of Work:_____________________________________
Check One:

(

) Single

(

) Coupled

( ) Widowed

No. Of Children:_____________________________

Name of Emergency Contact:________________________________Phone No.:__________________________________
Referred To This Office By:____________________________________________________________________________
Who Is Responsible For Your Bill? ( ) Self (
(

) Auto Insurance

) Spouse/Partner ( ) Worker’s Comp.

( ) Personal Health Insurance

(

) Other Party_________________________________________

CURRENT HEALTH CONDITION

_________________

Purpose Of This Appointment: __________________________________________________________________________
Other Doctors Seen For This Condition: ___________________________________________________________________
When Did This Condition Begin? ________________________________________________________________________
If Disabled From Work, Please Give Dates: ________________________________________________________________
(

) Job Related

(

) Auto Related

Current Medications: ( ) Pain Killers/Muscle Relaxers:___________________________________________________
(

) Nerve Pills:____________________________________ ( ) Blood Pressure Meds.:___________________________

(

) Insulin

( ) Other:______________________________________________________________________________

HEALTH HISTORY PART I
Major Accident or Falls:_______________________________________________________________________________
Broken Bones:_______________________________________________________________________________________
Major Surgery/Operations:______________________________________________________________________________
(

) Appendectomy ( ) Tonsillectomy

(

) Gall Bladder

( ) Hernia

(

) Other:_____________________

Hospitalizations (other than above):______________________________________________________________________
Previous Chiropractic Care: ( ) None

( ) Yes

Approx. Date of Last Visit:_______________________________

Name of Doctor:_____________________________________
Have you been treated for any health condition in the last year: (

Office Location:__________________________________________
) No

(

) Yes

If yes, please explain:_____________________________________________________________________________________________

HEALTH HISTORY PART II Please Check Any Of The Following Which Apply To You [ [ [ [ [ [ [ ] ] ] ] ] ] ] Anemia Measles Mumps Whooping Cough Diphtheria Chicken Pox Small Pox [ [ [ [ [ [ [ ] ] ] ] ] ] ] Rheumatic Fever Typhoid Fever Scarlet Fever Polio Tuberculosis Malaria Meningitis [ [ [ [ [ [ [ ] ] ] ] ] ] ] Pneumonia Pleurisy Diabetes Thyroid Disease Heart Disease HIV+/AIDS Cancer – Type _________ _____________________ _ [ [ [ [ [ [ [ ] ] ] ] ] ] ] Arthritis Skin Conditions Epilepsy Mental Disorder Venereal Infection Substance Dependencies Other: ______________ Please Check Any Of the Following Which Currently Apply To You (within the past 6 months). GENERAL [ ] Allergies [ ] Loss of sleep [ ] Fever [ ] Headaches MUSCULOSKELETAL [ ] Low Back Pain [ ] Pain Between Shoulders [ ] Neck Pain [ ] Arm Pain / Leg Pain [ ] Joint Pain / Swelling [ ] Walking Problems [ ] Difficulty Chewing/ Clicking Jaw NERVOUS SYSTEM [ ] Numbness [ ] Paralysis [ ] Dizziness [ ] Forgetfulness [ ] Confusion/Depression [ ] Fainting [ ] Convulsions [ ] Cold/Tingling Extremities URINARY SYSTEM [ ] Kidney Infection [ ] Kidney Stones [ ] Bladder Infection [ ] Bladder Problems [ ] Painful Urination [ ] Excessive Urination [ ] Discolored Urine GASTROINTESTINAL [ ] Poor/Excessive Appetite [ ] Excessive Thirst [ ] Frequent Nausea [ ] Vomiting [ ] Diarrhea [ ] Constipation [ ] Hemorrhoids [ ] Liver Problems [ ] Gallbladder Problems / Stones [ ] Weight Trouble [ ] Abdominal Cramps [ ] Gas/Bloating After Meals [ ] Heartburn [ ] Black/Bloody Stools [ ] Colitis CV / RESPIRATORY [ ] Chest Pain [ ] Shortness of Breath [ ] Blood Pressure Problems [ ] Irregular Heartbeat [ ] Heart Problems [ ] Lung Problems/Congestion [ ] Varicose Veins [ ] Leg/Ankle Swelling EENT [ ] Vision Problems [ ] Dental Problems [ ] Sore Throat [ ] Ear Aches [ ] Hearing Difficulties FEMALES ONLY [ ] Menstrual Irregularity [ ] Menstrual Cramping [ ] Vaginal Pain/Infection [ ] Reproductive Problems [ ] Genital Herpes [ ] Breast Pain/Lumps Are You Pregnant? [ ] Yes ( ) No ( ) Maybe When was your last Period? ______________________________ FEMALES OVER 40 [ ] Menopause Perimenopausal Symptoms [ ] Hot Flashes [ ] Night Sweats [ ] Vaginal Dryness [ ] Mood Sings [ ] Weight Gain [ ] Other Symptoms_________ ______________________________ MALES ONLY [ ] Prostate Problems [ ] Reproductive Problems [ ] Sexual Dysfunction [ ] Genital Herpes [ ] Other Symptoms_______ _____________________________ .

D = DULL S = STABBING B =BURNING T = TINGLING (Pins & Needles) N = NUMBNESS C = CRAMPING On the scales below. please draw a vertical line representing the intensity of your pain or discomfort. Rate the pain you have right now: NO PAIN UNBEARABLE PAIN Rate your pain at its best during the past week NO PAIN UNBEARABLE PAIN |________________________________________| |_____________________________________| Rate your pain on average during the past week: Rate your pain at its worst during the past week: NO PAIN NO PAIN UNBEARABLE PAIN UNBEARABLE PAIN |________________________________________| |_____________________________________| . Use the symbols shown to represent the types of pain.Please mark the location of your pain or discomfort on the images below.