activebodylasalle_Chiropractic_Health

Chiropractic Health History
Name:
Sex:
Age:
Today's Date:

MonthDayYear
Date
D.O.B:

MonthDayYear
Date
Address:
Cell #:
Work #:
Home #:
Best phone number to reach you at:
Email:
example@example.com
Employers Name / Occupation:
SingleMarriedDivorcedWidowed
Names & Ages of Children:
Reason for consulting this office?
Who may we THANK for referring you to our office?
Were you involved in a car accident or work injury that contributed to this injury?

YesNo
** If YES, please speak to the front desk to provide Claim number and complete forms.

As a full spectrum Chiropractic office, we focus on your ability to be healthy.

Our goals are, first to address the issues that brought you to this office, and second, to offer you the opportunity of improved health potential and wellness services in the future.

We experience physical, chemical and emotional stresses daily that can accumulate and result in serious loss of health potential. Most times the effects are gradual: not even felt until they become serious.
Briefly describe the chief area of complaint, including the effect it has had on your life.
Select the goals you may have for your chiropractic care:

Symptom reliefCorrective careWellness care
Primary area of concern:
Second area of concern:
The primary problem has persisted for_____days
The primary problem has persisted for_____monts
The primary problem has persisted for_____years
If you are experiencing pain, is it...

SharpDullComes and goesTravelingConstant
Since the problem started, it is...

About the sameGetter betterGetting worse
What makes it worse?
Yes, it interferes with:

WorkSleepWalkingSittingHobbiesLeisure
Notes:
List any medications you are taking:
Answering the following questions will give us a profile of the specific stresses you have faced in your lifetime, allowing us to better assess the challenges to your health potential.

Research is showing that many of the health challenges that occur later in life have their origins during the developmental years, some starting at birth. Please answer the following questions to the best of your ability.

	Yes	No	Unsure
Did you have any serious falls as a child?
Did you suffer any other trauma? (physical or emotional)
Have you been involved in any car accidents?

Comments:
On a scale of 1-10 describe your stress levels: (1=none, 10=extreme)
Occupational
Personal
Please check ( ) all symptoms you have had in the last 6 months, even if they do not seem related to your current problem.

HeadachesPins and needles in armsPins and needles in legsDizzinessNumbness in fingersNumbness in toesSleeping problemsDiarrheaConstipationSinusesLoss of smellLoss of tasteDepressionNeck stiffMood swingsLight bothers eyesMenstrual painMenstrual irregularityBack painRinging in earsBuzzing in earsIrritabilityCold handsCold feetProblem urinatingFaintingNeck PainLoss of balanceFatigueNervousnessStomach upsetTensionFeverHot flashesHeartburnUlcers
Other symptoms/notes:
Have you had any x-rays of your spine?
Other Doctors / treatment seen for this problem:
Chiropractor
Medical Doctor
Physio, massage
Verbal consent for Chiropractic examination

Yes
This Beginners Guide to Chiropractic is very helpful and informative please review the link below before submitting the form.

https://youtu.be/K8l9e0N1CTw?si=CdAchnYhssPasix7
Should be Empty:

Chiropractic Health History