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Patient Data
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Mailing Address
Telephone (Home)
Telephone (Work)
Referred By


Birth Date
Social Security #
Number of Children
Marital Status
Spouse's Name
Spouse's Occupation
Spouse's Employer 
Spouse's Health Status
Emergency Contact
Current Complaints
Nature of Injury
Please Describe
Date of Injury
Have you ever had same condition? 
If yes, when? 
List other practicioners seen for this injury/condition
Have you ever been under chiropractic care?
Insurance Information
Name of party responsible for payment 
Do you have health insurance?
Name of company
Medical History
Have you been treated for any
conditions in the last year?
If yes, please describe 
Date of last physical exam 
Is there a chance that you are pregnant?
Have you had X-rays taken?
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).
Have you ever:
Broken bones?
Briefly explain
Been hospitalized?
Briefly explain
Been in auto accident?
Had Sprains/Strains?
Briefly explain
Been struck unconscious?
Briefly explain
Had surgery?
Briefly explain
Family History
Family members - Present and past health conditions (Example: heart disease, cancer, diabetes, arthritis, etc.) 
Do you experience pain every day?
Do your symptoms interfere with daily life?
Does pain wake you up at night?
Are your symptoms worse during certain times of the day?
Do changes in weather affect your symptoms?
Do you wear orthotics?
Do you take vitamin supplements?
What activities aggravate your symptoms?
Soft Drinks
Salty Foods
Sugary Foods
Artificial Sweeteners
Have you ever suffered from:
Alcoholism Irregular Cycle
Allergies Kidney Infection
Anemia Kidney Stones
Arteriosclerosis Loss of memory
Arthritis Loss of balance
Asthma Loss of smell
Back Pain Loss of taste
Breast lump Lumps In Breast
Bronchitis Neck Pain or Stiffness
Bruise Easily Nervousness
Cancer Nosebleeds
Chest Pain/Conditions Pacemaker
Cold extremities Polio
Constipation Poor Posture
Cramps Prostate Trouble
Depression Sciatica
Diabetes Shortness of breath
Digestion Problems Sinus Infection
Dizziness Sleep problems/insomnia
Ears Ring Spinal Curvatures
Excessive Menstruation Stroke
Eye Pain/Difficulties Swelling of ankles
Fatigue Swollen Joints
Frequent Urination Thyroid Condition
Headache Tuberculosis
Hemorrhoids Ulcers
High Blood Pressure Varicose Veins
Hot Flashes Venereal Disease
Irregular Heart Beat Other:



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