Name *

Date Of Birth *

Age *

What you prefer to be called

Gender* Select GenderMaleFemaleOther

SSN

Height

Weight

Marital Status* Select Marital StatusSingleMarriedWidowDivorcedSeparated

Children

Home Address *

Home/Mobile Phone *

City/State/Zip *

Spouse Name

Picture Maximum upload file size: 2 MB

Employer

Occupation

Work Address

Work Phone

City/ State/ Zip

Referred by

Have you ever been treated by a Chiropractic physician?

Yes No

If so please explain

Date of last treatment

Medical doctor's name

Phone

Reason for visit *

Explain what happened *

Date condition began

Describe location of condition or pain

Is pain * Select PainDullSharpAchyBurningShootingDeepSuperficialMildModerateSevereConstantFrequentOccasional

What makes it better? *

What makes it worse? *

Does this affect how you work, sleep, etc.? *

Yes No

If so, explain:

Have you had this or similar conditions in the past? *

Yes No

How long ago?

Have you tried any home remedies?

Have you seen any other physician for this condition?

Yes No

Date of last treatment

Taking any medication for condition (list)? *

Have you had any x-rays taken *

Yes No

If so, when and where?

Please list any other serious medical conditions you have or ever had

Dr.Notes

Other

Past Surgeries & Dates

Past Injuries/ Fractures *

Auto Accidents & Dates

Known Allergies

All Medications

Do You Smoke?

Yes No

How Long?

Do You Alcohol?

Yes No

How Often?

Do You Exercise?

Never Occasional Regular Excessive

Are you wearing lifts or supports in your shoes?

Yes No

Support Type

Mattress

Firm Medium Soft

How do you sleep?

Back Side StomachPillows

How many pillows do you sleep with ?