Business Address Phone

Name Birthday

Home Address Phone

City, State, Zip

City, State, Zip Email address

Sex M F Usual occupation

Employer

Living Situation Alone parents spouse friends boarding

Referred by

Marital status never married now married divorced widowed

number of children number living with you

Employment status school keeping house work fulltime part time

unemployed disabled retired

Medical insurance Agent

Address Phone

City, State, Zip

ID Number Social Sec.#

Person to be contacted in case of emergency

Address Phone

City, State, Zip

Members of household:

Name	Age	Relationship

Are you allergic to any drugs, (penicillin, etc..)

Any other allergies

Do you have any housing problems? (heating, rats, roaches, paint peeling)

Do you have any worrisome financial problems? Yes No

Do you have transportation problems getting here? Yes No

Have you been hospitalized recently? Yes No More than three times? Yes No

Give the following information for the last times you have been hospitalized starting with the most recent (except for normal pregnancies)

	Hospitalization 1	Hospitalization 2	Hospitalization 3
Type of operation or illness
Month and year hospitalized
Name of hospital
City and state

Medical History

Check any boxes in the appropriate column for any illnesses related to any relatives alive or dead

Do you Use?

Yes Amount

Coffee

Cigarettes

Alcohol

Aspirin

Birth control pills

Sedatives/Tranquilizers

Thyroid

Laxatives

Cortisone

Hormones

Drugs

Medicinal Herbs,

Teas, Vitamins

If you have had any of the following tests or immunizations check the appropriate box and, if you can,

give the year you last had them

Year Tests Year Immunizations

Chest X-ray Smallpox

Kidney X-ray (I.V.P.) Tetanus

G.I. Series Polio

Colon X-ray (Barium Enema) Typhoid

Gallbladder X-ray (Cholecystogram) Flu

Electrocardiogram Mumps

T.B. test Measles

Other X-rays Other

Have you had any of the following as an adult or during childhood? :

High fever Car accident(s) date(s)

Severe flu Any skin conditions treated by a Dermatologist or Podiatrist (explain)

Blood transfusion reaction

Injury requiring stitches

Fracture(s) Explain

Any prolonged illness (please describe)

Work exposure to chemicals or fumes

Have you ever had Chiropractic care? Yes No Date of last treatment

WOMEN:

Date of last normal menstrual period Period occurs every days

Amount of flow Duration Regular Cramps

Birth control methods if applicable

FOOD

Typical Breakfast

Snack

Typical lunch

Snack

Typical dinner

Snack

Do you crave certain foods?

Do certain foods disagree with you?

How many glasses of water do you drink in one day?

Please list the main complaints that you have

If you have recently been bothered with these problems check Yes.

Have you ever experienced an emotional, spiritual or physical incident from which you feel you have never recovered your

previous level of health?

Please explain briefly.

Please print this form and bring to office

(Go to File Print, in Browser window)

	You	Father	Mother	Bro/Sis1	Bro/Sis2	Bro/Sis3	Child1	Child2	Grand1	Grand2	Grand3
Allergies
Anemia
Anorexia
Arthritis
Asthma
Bleeding/bruising
Bulimia
Cancer/tumors
Convulsions/epilepsy
Diabetes
Drinking/drugs
Eczema
Emphysema
Gallstones
Heart trouble
Hepatitis
High blood pressure
Frequent infections
Kidney/bladder problems
Mental illness
Migraines
Abnormal periods
Psoriasis
Pneumonia
Polio
Prostate problem
Tuberculosis
Ulcers
Venereal disease
Weight problem

Yes		Yes		Yes
	Frequent or severe headaches		Recurring indigestion		Aching muscles or joints
	Neck pains		Frequent belching		Swollen joints
	neck lumps or swelling		nausea		back or shoulder pains
	loss of balance		vomiting		weakness in arms or legs
	dizzy spells		pain in abdomen		painful feet
	blackouts/fainting		bloated abdomen		trembling
	wear glasses		constipation		numbness
	blurry vision		loose bowls		leg cramps
	eyesight worsening		black stools		skin problems
	see double		grey or whitish stools		scalp problems
	see halos or lights		pain in rectum		itching or burning skin
	eye pains or itching		itching rectum		bruise easily
	watering eyes		blood with stools
			symptoms if late/miss a meal		nervousness or anxiety
	hearing difficulties				nervous with strangers
	earaches		frequent urination		nail biting
	running ears		involuntary escape or urine		difficulty making decisions
	noises in ears		burning on urination		lack of concentration
			brown/black/bloody urine		absentminded/memory loss
	dental problems		weak urine stream		lonely or depressed
	sore or bleeding gums		difficulty starting urine		frequent crying
	sore tongue		constant urge to urinate		hopeless outlook
					difficulty relaxing

congested nose	Men Only	worry a lot
running nose	burning or discharge	frightening dreams or thoughts
sneezing spells	lumps or swelling on testicles	feeling of depression
head colds	painful testicles	shy or sensitive
nosebleeds		dislike criticism
sore throat	Women Only	angered easily
difficulty swallowing	a missed period	annoyed by little things
hoarse voice	menstrual problems	family problems
	bleeding between periods	problems at work
wheezing or gasping	tension or pain between periods	sexual difficulties
frequent coughing	heavy bleeding	changes of sexual energy
coughing phlegm	bearing down feeling	considered suicide
cough up blood	vaginal discharge	sought psychiatric help
chest colds	genital irritation	hot flashes
	pain on intercourse	loss or gain in weight
rapid or skipped heartbeats	swelling or lumps in breasts	frequently feel warmer or colder than others
chest pains	painful breasts	loss of appetite
shortness of breath with normal activity		always hungry
swollen feet or ankles	number of pregnancies	armpits or groin swelling
shortness of breath with ascending steps or hill	number of births	unusual fatigue or wariness
	miscarriages	difficulty sleeping
	premature births	fever or chills
	cesareans	motion sickness
	abortions	excessive sweating
		night sweats