Welcome to our office.
It’s an honor to be of service to you.
Please complete the following confidential health history.
* Denotes a Required Field
        
Name:*
Preferred name:
Address:*
 
City:*
State:*
Zip:*
At least one phone number is required.
Home phone number:
Work phone number:
Cell phone number:
E-mail:*
Male/Female:*
 Male Female
Birth date:*
Age:*
Your occupation:*
Emergency contact:*
Relationship:*
Phone number:*
Whom may we thank for referring you to us?

For Insurance Purposes:
Marital Status:*
 Single Married Divorced Widowed
Primary insurance
Name of insurance company:*
Contract number: *
Group number: *
Is your insurance policy under your name?*
 Yes No
If not, whose name is it under?
What is your relationship to this person?
Birth date of insured:
Phone number of insurance company (on back of card):*
Address of the insurance company (on back of card):*
Secondary insurance
Name of insurance company:
Contract number:
Group number:
Is your insurance policy under your name?
 Yes No
If not, whose name is it under?
What is your relationship to this person?
Birth date of insured:
Phone number of insurance company (on back of card):
Address of the insurance company (on back of card):

Health History:

Section 1
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:  
  When did it start?  
  What are you currently doing for this?
   
  Is it helping?  
Health Issue 2:  
  When did it start?  
  What are you currently doing for this?
   
  Is it helping?  
Health Issue 3:  
  When did it start?  
  What are you currently doing for this?
   
  Is it helping?  
Health Issue 4:  
  When did it start?  
  What are you currently doing for this?
   
  Is it helping?  
Health Issue 5:  
  When did it start?  
  What are you currently doing for this?
   
  Is it helping?  
Others:

List your surgeries.
1.  
2.  
3.  
4.  
5.  
Others:


List any supplement/s, vitamin/s, herb/s, homeopathic/s, medication/s you are taking and the reason for which you are taking them:
1.  
      Reason:  
2.  
      Reason:  
3.  
      Reason:  
4.  
      Reason:  
5.  
      Reason:  
Others:

Please list your health concern/s in order of severity:
First concern*
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?

Second concern
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?

Third concern
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?


Lifestyle:
Alcohol*   
None Daily Weekly Monthly
Coffee*   
None Daily Weekly Monthly
Soda*   
None Daily Weekly Monthly
Sweets/Refined Carbohydrates* 
None Daily Weekly Monthly
Soy Products*   
None Daily Weekly Monthly
Protein*   
None Daily Weekly Monthly
Fresh Fruits/Veggies*   
None Daily Weekly Monthly
White Flour*   
None Daily Weekly Monthly
Milk/Dairy*   
None Daily Weekly Monthly
Juice*   
None Daily Weekly Monthly
Meat/Fish*   
None Daily Weekly Monthly
 
Are you vegetarian?*
Yes No
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 smoke cigarettes/cigars, use nicotine gum, or chew tobacco?*
Yes No
If yes, please explain
If you do not smoke, 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 would you describe your job?* Check all that apply.
          Physical
          Mental
          Stressful
          Exhausting
          Relaxing
          Secure
          Non-secure
How many hours do you work in an average week?*
How often do you exercise?*
Never Rarely Sometimes Regularly Competatively
Sleep Habits
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?*
Yes No
If yes, how long has this been happening?

Section 2 (Men Only)
Answer "yes" to anything that applies to you; no check assumes the answer is no.
What was the date of your last physical?
Were there any unusual findings?
Have you had a vasectomy?
Yes
If yes, when?
Have you had a reverse vasectomy?
Yes
If yes, when?
Do you have a history of prostate problems?
Yes
If yes, explain.
When was the date of your last prostate exam?
What is your most recent PSA result?
Date?

Signs & Symptoms
Low Mood/Depression
Yes
Mild Moderate Severe
Additional comments:  
 
Irritability
 Yes
Mild Moderate Severe
Additional comments:  
 
Anxiety
 Yes
Mild Moderate Severe
Additional comments:  
 
Anger/Aggression
 Yes
Mild Moderate Severe
Additional comments:  
 
Discouragement/Pessimism
 Yes
Mild Moderate Severe
Additional comments:  
 
Decreased interest in activities/relationships
 Yes
Mild Moderate Severe
Additional comments:  
 
Decreased initiative/motivation/drive
 Yes
Mild Moderate Severe
Additional comments:  
 
Decreased productivity at work
 Yes
Mild Moderate Severe
Additional comments:  
 
Concentration problems
 Yes
Mild Moderate Severe
Additional comments:  
 

Memory problems
 Yes
Mild Moderate Severe
Additional comments:  
 

Foggy thinking
 Yes
Mild Moderate Severe
Additional comments:  
 

Increased fatigue
 Yes
Mild Moderate Severe
Additional comments:  
 

Decrease in strength/stamina
 Yes
Mild Moderate Severe
Additional comments:  
 

Decrease in athletic performance
 Yes
Mild Moderate Severe
Additional comments:  
 

Decreased lean muscle mass
 Yes
Mild Moderate Severe
Additional comments:  
 

Muscle soreness/weakness
 Yes
Mild Moderate Severe
Additional comments:  
 

Body/joint aches
 Yes
Mild Moderate Severe
Additional comments:  
 
Weight loss
 Yes
Mild Moderate Severe
Additional comments:  
 
Weight gain
 Yes
Mild Moderate Severe
Additional comments:  
 
Increased fat on hips/breasts/thighs
 Yes
Mild Moderate Severe
Additional comments:  
 
Low blood sugar/Hypoglycemia
 Yes
Mild Moderate Severe
Additional comments:  
 
Sweet cravings/Carbs/Chocolate
Yes
Mild Moderate Severe
Additional comments:  
 
Caffeine/Stimulant cravings
Yes
Mild Moderate Severe
Additional comments:  
 
Salt cravings
 Yes
Mild Moderate Severe
Additional comments:  
 
Constant hunger
 Yes
Mild Moderate Severe
Additional comments:  
 
Elevated cholesterol
 Yes
Mild Moderate Severe
Additional comments:  
 
Elevated blood pressure
 Yes
Mild Moderate Severe
Additional comments:  
 
Bloating/Belching/Gas
 Yes
Mild Moderate Severe
Additional comments:  
 
Stomach burning/Nausea/Indigestion
Yes
Mild Moderate Severe
Additional comments:  
 
Constipation
Yes
Mild Moderate Severe
Additional comments:  
 
Loose stool/Diarrhea/IBS
Yes
Mild Moderate Severe
Additional comments:  
 
Light-colored stool
 Yes
Mild Moderate Severe
Additional comments:  
 
Head hair loss
 Yes
Mild Moderate Severe
Additional comments:  
 
Need to shave less frequently
 Yes
Mild Moderate Severe
Additional comments:  
 
Body hair loss
 Yes
Mild Moderate Severe
Additional comments:  
 
Dry skin/thinning skin
 Yes
Mild Moderate Severe
Additional comments:  
 
Decreased spontaneous morning erections
 Yes
Mild Moderate Severe
Additional comments:  
 
Lowered libido
 Yes
Mild Moderate Severe
Additional comments:  
 
Erectile Dysfunction (ED)
 Yes
Mild Moderate Severe
Additional comments:  
 
Pain with ejaculation
 Yes
Mild Moderate Severe
Additional comments:  
 
Frequent need to urinate
 Yes
Mild Moderate Severe
Additional comments:  
 
Urination is delayed/strained/incomplete
 Yes
Mild Moderate Severe
Additional comments:  
 
Pain with urination
 Yes
Mild Moderate Severe
Additional comments:  
 
Blood in the urine
 Yes
Mild Moderate Severe
Additional comments:  
 
Bone loss/osteoporosis
 Yes
Mild Moderate Severe
Additional comments:  
 
Other symptoms:
 
Is there anything else you would like to share that you feel would be helpful
for us to know?
 
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