Chiropractic Intake Form Please complete this questionnaire. Your answers will help determine if Chiropractic can help you. Please answer ALL questions, even if they seem unrelated to your case. There are conditions Chiropractic can help that you may be unaware of. If we do not sincerely believe your condition will respond satisfactorily, we will not accept your case. NameAHC#Email SexSexMFN-BPhone (H)Phone (W)Phone (C)Address Street Address City State / Province / Region ZIP / Postal Code Marital StatusAgeWeightHeightChildrenBirth DateBirth PlaceEmployerOccupationFamily DoctorReferred ByReminders Preference Email Text Phone Emergency Contact Name First Name Phone Number CURRENT HEALTH CONDITIONPresent Complaint?Have you had any previous treatment for this condition?YesNoWhen did this condition begin?Are there others in you family with this same condition?Have you had any time loss from work for this condition? (If yes, recent list dates)Is this a WCB Case?YesNoIf yes, WCB case and date of accidentAre you presently taking medication? (please mention)When is the last time you really felt well?How important is your health to you on a scale of 1 – 10, 10 being the most important?12345678910PAST HEALTH HISTORYMajor surgery/operations: eg) Appendix, Tonsils, Hernia, Tubes in ears, other? If yes, please explain.Major accidents or falls, fracture? If yes, please explain.Previous ChiropractorPrevious Chiropractor date of last visitHave you been treated for any health condition in the last year? If yes, please explain.Please check any of the following conditions that are a problems (now or in the past).General headache Numbness or pain dizziness ringing in ears whiplash fainting earache sore throat nose bleeds sinus problems asthma enlarged glands loss of weight hypoglycaemia nervousness depression/confusion vision problems dental problems hearing problems Organs frequent urination painful urination blood in urine bladder trouble kidney stones bed wetting prostate problems sexual dysfunction anemia thyroid excessive appetite gas/bloating nausea or vomiting constipation/diarrhea colitis black/bloody stool hemorrhoids liver trouble gall bladder trouble Muscle & Joint low back problems neck problems sore joints painful tailbone pain between shoulders arthritis sore muscles walking problems broken bones difficulty chewing/ clicking ankle swelling Skin eczema skin eruptions varicose veins Respiratory & Heart lung problems chronic cough spit up blood shortness of breath/difficult breathing heart problems Females Only painful periods numbness or irregular cycle cramps, backache vaginal discharge/infection lumps/pain in breast menopausal symptoms previous miscarriage unable to get pregnant hot flashes Are you on birth control?YesNoAre you pregnant?YesNoNot sureWhen was your last period? MM slash DD slash YYYY Check any of the following conditions you have had alcoholism epilepsy sexually transmitted diseases stroke arthritis hypoglycaemia tuberculosis rheumatic fever diabetes cancer allergies heart disease Has anyone in your family had any of the following diseases? heart disease high blood pressure cancer stroke arthritis HABITSExercise None Light Moderate heavy Sleep None Light Moderate heavy Coffee None Light Moderate heavy Tea None Light Moderate heavy Tobacco None Light Moderate heavy Alochol None Light Moderate heavy Junk Food None Light Moderate heavy Stress None Light Moderate heavy Why Chiropractic? People go to chiropractors for a variety of reasons. Some go for symptomatic relief of pain or discomfort (Relief Care). Others are interested in having the cause of the problem as well as the symptoms corrected and relieved (Corrective Care). Still others want whatever is malfunctioning in their bodies brought to the highest state of health possible with Chiropractic Care (Wellness). These are the three phases of care. Your doctor will weigh your needs and desires when recommending your schedule of care. However, this prepared recommendation is in incorporation of all three phases.Please check the type of care desired so that we may be guided by your wishes whenever possible. Relief/Initial intensive care Corrective/Rehabilitative care Wellness/Maintenance care CAPTCHA
