Name:*

Preferred name:

Address:*

City:*

State:*

Zip:*

Home phone number:

Work phone number:

Cell phone number:

E-mail:*

Male/Female:*

Birth date:*

Age:*

Emergency contact:*

Relationship:*

Phone number:*

Whom may we thank for referring you to us?

Marital Status:*

Name of insurance company:*

Contract number: *

Group number: *

What name is on the insurance?*

What is the relationship to the patient?

Birth date of insured:

Phone number of insurance company (on back of card):*

Address of the insurance company (on back of card):*

Name of insurance company:

Contract number:

Group number:

What name is on the insurance?

What is the relationship to the patient?

Birth date of insured:

Phone number of insurance company (on back of card):

Address of the insurance company (on back of card):

Is this your first chiropractic experience? Yes No

If no, please describe your past care:

Is this your first clinical nutrition experience? Yes No

If no, please describe your past care:

List your previously diagnosed health issue/s.
For example: diabetes, high blood pressure, IBS, etc…

Health Issue 1:  

Health Issue 2:  

Health Issue 3:  

Health Issue 4:  

Health Issue 5:  

List your surgeries.

1.  

2.  

3.  

4.  

5.  

List any supplement/s, vitamin/s, herb/s, homeopathic/s you are taking and the reason for which you are taking them:

1.  

      Reason:  

2.  

      Reason:  

3.  

      Reason:  

4.  

      Reason:  

5.  

      Reason:  

When did this start?*

How did this start? Was there a specific event?*

Was it a sudden or gradual onset?*

How does it feel?*

If there is pain, does it stay in one place or does it travel?*

If it travels where does it travel to?*

What makes it feel better?*

What makes it feel worse?*

What time of the day is it better?*

What time of the day is it worse?*

What do you think is the cause of this?*

What other test/s, procedure/s have you had in regards to this issue?*

What have been the results of this/these procedure/s?*

Is there anything else you would like to mention regarding this issue?

When did this start?

How did this start? Was there a specific event?

Was it a sudden or gradual onset?

How does it feel?

If there is pain, does it stay in one place or does it travel?

If it travels where does it travel to?

What makes it feel better?

What makes it feel worse?

What time of the day is it better?

What time of the day is it worse?

What do you think is the cause of this?

What other test/s, procedure/s have you had in regards to this issue?

What have been the results of this/these procedure/s?

Is there anything else you would like to mention regarding this issue?

When did this start?

How did this start? Was there a specific event?

Was it a sudden or gradual onset?

How does it feel?

If there is pain, does it stay in one place or does it travel?

If it travels where does it travel to?

What makes it feel better?

What makes it feel worse?

What time of the day is it better?

What time of the day is it worse?

What do you think is the cause of this?

What other test/s, procedure/s have you had in regards to this issue?

What have been the results of this/these procedure/s?

Is there anything else you would like to mention regarding this issue?

Soda*   

Sweets/Refined Carbohydrates* 

Soy Products*   

Protein*   

Fresh Fruits/Veggies*   

White Flour*   

Milk/Dairy*   

Juice*   

Meat/Fish*   

Are you vegetarian?*

If yes, please explain

We have on staff a certified nutritionalist. Would you like to be contacted for a personalized review of your diet and meal planning strategies?*
Yes No

Do you live in a household where smoke is present?
Yes No

How would you rate your stress level?*
None 1 2 3 4 5 6 7 8 9 10 Extreme

How would you rate your stress handing?*
Poor 1 2 3 4 5 6 7 8 9 10 Excellent

How often do you exercise?*
Never Rarely Sometimes Regularly Competatively

How do you sleep?*
Well Trouble Falling Asleep Trouble Staying Asleep Insomnia

If you do not sleep well, how long has this been going on?

How many hours do you sleep a night on average?*

Do you wake up tired?*

If yes, how long has this been happening?

Answer "yes" to anything that applies to your child; no check assumes the answer is no.

Does your child have any known drug allergies?     Yes

If yes, please explain.

Does your child have a history of antibiotic use?     Yes

If yes, please explain.

Has your child been vaccinated?     Yes

If yes, please list the date/s of their vaccination/s.

Please describe any reactions that your child has had to past or recent vaccinations:

Was your child colic as an infant?     Yes

How was your child fed as an infant?     Breast Bottle

If bottle, what brand/kind of formula?    

Has your child had any respiratory infections? Yes

If yes, how often?

Does your child ever complain of back or neck pain? Yes

If yes, please explain.

Does your child ever complain of arm or leg pain?     Yes

If yes, please explain.

Does your child ever complain of headaches?     Yes

If yes, please explain.

Does your child play sports?     Yes

If yes, which one/s?

Has your child had ear infections?     Yes

If yes, at what age did they first occur, and their frequency?

Do they typically occur in the same ear?
   Yes, the left ear Yes, the right ear No, both ears

List any illness that your child has had and the approximate dates of occurrence.

Is there anything else you would like to share that you feel would be helpful for us to know?