Chiropractic Intake Form - Temple Crossing Chiropractic

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.

Name

AHC#

Email

Sex

Phone (H)

Phone (W)

Phone (C)

Marital Status

Age

Weight

Height

Birth Date

Birth Place

Employer

Occupation

Family Doctor

Referred By

Emergency Contact

CURRENT HEALTH CONDITION

Present Complaint?

Have you had any previous treatment for this condition?

When 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?

If yes, WCB case and date of accident

Are 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?

PAST HEALTH HISTORY

Major surgery/operations: eg) Appendix, Tonsils, Hernia, Tubes in ears, other? If yes, please explain.

Major accidents or falls, fracture? If yes, please explain.

Previous Chiropractor

Previous Chiropractor date of last visit

Have 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).

Are you on birth control?

Are you pregnant?

When was your last period?

HABITS

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.

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