Home
About Us
Services & Technique
Testimonials
Patient Forms
Contact
Schedule an Appointment
Home
About Us
Services & Technique
Testimonials
Patient Forms
Contact
Schedule an Appointment
Adult Patient Questionnaire
Open Form
Adult Patient Questionnaire
CONFIDENTIAL PATIENT INFORMATION
Name
First Name
Last Name
Date of Birth
MM
DD
YYYY
Sex
Male
Female
Height
Weight (lbs)
Occupation
Marital Status
Single
Married
Separated
Divorced
Widowed
# of Children
0
1
2
3
4
5
6
7
8
9
Street Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
Cell Phone #
Other Phone #
Emergency Contact
First Name
Last Name
Emergency Relation
Emergency Phone #
How did you hear about us?
Who is your primary care physician?
Date and reason for your last doctor visit
Are you also receiving care from any other health professionals?
Yes
No
If yes, please name them and their specialty
Please note any significant family medical history
CURRENT HEALTH CONDITIONS
What health condition(s) bring you into our office?
Have you received care for this problem before?
Yes
No
If yes, please explain:
When did the condition(s) first begin?
How did the problem start?
Suddenly
Gradually
Post-Injury
Is the condition
Getting worse
Improving
Intermittent
Constant
Unsure
What makes the problem better?
What makes the problem worse?
YOUR HEALTH GOALS
What are your top three health goals?
CHIROPRACTIC HISTORY
What would you like to gain from chiropractic care?
Resolve existing condition(s)
Overall wellness
Both
Have you ever visited a chiropractor?
Yes
No
If yes, what is their name?
What is their specialty?
Pain Relief
Physical Therapy & Rehab
Nutritional
Subluxation-based
Other
Do you have any health concerns for other family members today?
TRAUMAS: PHYSICAL INJURY HISTORY
Have you ever had any significant falls, surgeries, or other injuries as an adult?
Yes
No
If yes, please explain
Notable childhood injuries?
Yes
No
If yes, please explain
Youth or college sports?
Yes
No
If yes, please explain
Any auto accidents?
Yes
No
If yes, please explain
Exercise frequency?
None
1-2 times per week
3-5 times per week
Daily
What types of exercise?
How do you normally sleep?
Back
Side
Stomach
Do you wake up
Refreshed and ready
Stiff and tired
Do you commute to work?
Yes
No
If yes, how many minutes per day?
List any problems with flexibility (ex. Putting on shoes/socks, etc.)
How many hours per day do you typically spend sitting at a desk or on a computer, tablet, or phone?
TOXINS: CHEMICAL & ENVIRONMENTAL EXPOSURE - PLEASE RATE YOUR CONSUMPTION FOR EACH
Alcohol
1 (None)
2
3 (Moderate)
4
5 (High)
Water
1 (None)
2
3 (Moderate)
4
5 (High)
Sugar
1 (None)
2
3 (Moderate)
4
5 (High)
Dairy
1 (None)
2
3 (Moderate)
4
5 (High)
Gluten
1 (None)
2
3 (Moderate)
4
5 (High)
Processed Foods
1 (None)
2
3 (Moderate)
4
5 (High)
Artificial Sweeteners
1 (None)
2
3 (Moderate)
4
5 (High)
Sugary Drinks
1 (None)
2
3 (Moderate)
4
5 (High)
Cigarettes
1 (None)
2
3 (Moderate)
4
5 (High)
Recreational Drugs
1 (None)
2
3 (Moderate)
4
5 (High)
Please list any drugs/medications/vitamins/herbs/other that you are taking, and why
EMOTIONAL STRESSES & CHALLENGES: PLEASE RATE YOUR STRESS FOR EACH
Home
1 (None)
2
3 (Moderate)
4
5 (High)
Work
1 (None)
2
3 (Moderate)
4
5 (High)
Life
1 (None)
2
3 (Moderate)
4
5 (High)
Money
1 (None)
2
3 (Moderate)
4
5 (High)
Health
1 (None)
2
3 (Moderate)
4
5 (High)
Family
1 (None)
2
3 (Moderate)
4
5 (High)
ACKNOWLEDGEMENT & CONSENT
Patient Signature
*
Please enter your name.
First Name
Last Name
Today's Date
*
MM
DD
YYYY
Thank you! Your information is confidential and will not be shared with anyone.
Pediatric Patient Questionnaire
Open Form
Pediatric Patient Questionnaire
CONFIDENTIAL PATIENT INFORMATION
Child's Name
First Name
Last Name
Parent/Guardian Name(s)
First Name
Last Name
Street Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Cell Phone
Other Phone
Parent/Guardian Email
Child's Birthdate
MM
DD
YYYY
Child's Age
How did you hear about us?
Height
Weight (lbs)
Who is your primary care physician?
Is your child receiving care from any other health professionals?
Yes
No
If yes, please name them and their specialty
Please list any drugs/medications/vitamins/herbs/other that your child is taking
CURRENT HEALTH CONDITIONS
What health condition(s) bring your child to be evaluated by a chiropractor?
When did the condition(s) first begin?
How did the problem start?
Suddenly
Gradually
Post-Injury
Has your child ever received care for this condition before?
Yes
No
If yes, please explain
Is this condition
Getting worse
Improving
Intermittent
Constant
Unsure
What makes the problem better?
What makes the problem worse?
HEALTH GOALS FOR YOUR CHILD
What are your top three health goals for your child?
What would you like to gain from chiropractic care?
Resolve existing condition
Overall wellness
Both
Have you ever visited a chiropractor?
Yes
No
If yes, what is their name?
What is their specialty?
Pain Relief
Physical Therapy & Rehab
Nutritional
Subluxation-based
Other
PREGNANCY & FERTILITY: Please tell us about your pregnancy
Any fertility issues?
Yes
No
If yes, please explain
Did mother smoke?
Yes
No
If yes, how many per week?
Did mother drink?
Yes
No
If yes, how many per week?
Did mother exercise?
Yes
No
If yes, please explain
Was mother ill?
Yes
No
If yes, please explain
Any ultrasounds?
Yes
No
If yes, please explain
Please explain any notable episodes of mental or physical stress during your pregnancy
Please explain any other concerns or notable remarks about your child's conception or pregnancy
LABOR & DELIVERY HISTORY
Child's birth was
Natural vaginal birth
Scheduled C-section
Emergency C-section
At how many weeks was your child born?
Child's birth was
At home
At a birthing center
At a hospital
Other
If "Other", please explain
Doctor/Obstetrician's Name
Please check any applicable interventions or complications
Breech
Induction
Pain meds
Epidural
Episiotomy
Vacuum extraction
Forceps
Other
If "Other", please explain
Please describe any other concerns or notable remarks about your child's labor and/or delivery
Child's birth weight (lbs, oz)
Child's birth height (inches)
APGAR score at birth
APGAR score after 5 minutes
GROWTH & DEVELOPMENT HISTORY
Is/was your child breastfed?
Yes
No
If yes, how long?
Difficulty with breastfeeding?
Yes
No
Did they ever use formula?
Yes
No
If yes, at what age and what type?
Did/does your child ever suffer from colic, reflux, or constipation as an infant?
Yes
No
If yes, please explain
Did/does your child frequently arch their neck/back, feel stiff, or bang their head?
Yes
No
If yes, please explain
At what age did the child
Respond to sound?
Follow an object?
Hold their head up?
Vocalize?
Teethe?
Sit alone?
Crawl?
Walk?
Begin cow's milk?
Begin solid foods?
Please list any food intolerance or allergies, and when they began
Please list your child's hospitalization and surgical history, including the year
Please list any major injuries, accidents, falls and/or fractures your child has sustained in his/her lifetime, including the year
Have you chose to vaccinate your child?
Yes, on schedule
Yes, on a delayed or selective schedule
No
If yes, please list any vaccination reactions
Has your child received any antibiotics?
Yes
No
If yes, how many times and list reason
Night terrors or difficulty sleeping?
Yes
No
If yes, please explain
Behavioral, social, or emotional issues?
Yes
No
If yes, please explain
How many hours per day does your child typically spend watching a TV, computer, tablet, or phone?
How would you describe your child's diet?
Mostly whole, organic foods
Pretty average
High amount of processed foods
ACKNOWLEDGEMENT & CONSENT
Patient Signature
*
Please enter your name.
First Name
Last Name
Today's Date
*
MM
DD
YYYY
Thank you! Your information is confidential and will not be shared with anyone.
Pregnancy Questionnaire
Open Form
Pregnancy Questionnaire
CONFIDENTIAL PATIENT INFORMATION
Patient Name
*
First Name
Last Name
Date of Birth
MM
DD
YYYY
Sex
Male
Female
Street Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
Cell Phone #
Other Phone #
Marital Status
Single
Married
Separated
Divorced
Widowed
Occupation
# of Children
0
1
2
3
4
5
6
7
8
9
Height
Weight (lbs)
Emergency Contact
First Name
Last Name
Emergency Relation
Emergency Phone #
How did you hear about us?
Who is your primary care physician?
Date and reason for your last doctor visit
Are you also receiving care from any other health professionals?
Yes
No
If yes, please list their name and specialty
Please note any significant family medical history
CURRENT HEALTH CONDITIONS
What health condition(s) bring you into our office?
Have you received care for this problem before?
Yes
No
If yes, please explain
When did the condition(s) first begin?
How did the problem start?
Suddenly
Gradually
Post-Injury
Is this condition
Getting worse
Improving
Intermittent
Constant
Unsure
What makes the problem better?
What makes the problem worse?
YOUR HEALTH GOALS
What are your top three health goals?
CHIROPRACTIC HISTORY
What would you like to gain from chiropractic care?
Resolve existing condition(s)
Overall wellness
Both
Have you ever visited a chiropractor?
Yes
No
If yes, what is their name?
What is their specialty?
Pain Relief
Physical Therapy & Rehab
Nutritional
Subluxation-based
Other
Do you have any health concerns for other family members today?
TRAUMAS: PHYSICAL INJURY HISTORY
Have you ever had any significant falls, surgeries, or other injuries as an adult?
Yes
No
If yes, please explain
Notable childhood injuries?
Yes
No
If yes, please explain
Youth or college sports?
Yes
No
If yes, list major injuries
Any auto accidents?
Yes
No
If yes, please explain
Exercise frequency?
None
1-2 times per week
3-5 times per week
Daily
What types of exercise?
How do you normally sleep?
Back
Side
Stomach
Do you wake up
Refreshed and ready
Stiff and tired
Do you commute to work?
Yes
No
If yes, how many minutes per day?
List any problems with flexibility (ex. Putting on shoes/socks, etc.)
How many hours per day do you typically spend sitting at a desk or on a computer, tablet, or phone?
TOXINS: CHEMICAL & ENVIRONMENTAL EXPOSURE - PLEASE RATE YOUR CONSUMPTION FOR EACH
Alcohol
1 (None)
2
3 (Moderate)
4
5 (High)
Water
1 (None)
2
3 (Moderate)
4
5 (High)
Sugar
1 (None)
2
3 (Moderate)
4
5 (High)
Dairy
1 (None)
2
3 (Moderate)
4
5 (High)
Gluten
1 (None)
2
3 (Moderate)
4
5 (High)
Processed Foods
1 (None)
2
3 (Moderate)
4
5 (High)
Artificial Sweeteners
1 (None)
2
3 (Moderate)
4
5 (High)
Sugary Drinks
1 (None)
2
3 (Moderate)
4
5 (High)
Cigarettes
1 (None)
2
3 (Moderate)
4
5 (High)
Recreational Drugs
1 (None)
2
3 (Moderate)
4
5 (High)
Please list any drugs/medications/vitamins/herbs/other that you are taking, and why
EMOTIONAL STRESSES & CHALLENGES: PLEASE RATE YOUR STRESS FOR EACH
Home
1 (None)
2
3 (Moderate)
4
5 (High)
Work
1 (None)
2
3 (Moderate)
4
5 (High)
Life
1 (None)
2
3 (Moderate)
4
5 (High)
Money
1 (None)
2
3 (Moderate)
4
5 (High)
Health
1 (None)
2
3 (Moderate)
4
5 (High)
Family
1 (None)
2
3 (Moderate)
4
5 (High)
ACKNOWLEDGEMENT & CONSENT
Patient Signature
*
Please enter your name.
First Name
Last Name
Today's Date
*
MM
DD
YYYY
Thank you! Your information is confidential and will not be shared with anyone.
Progress Report
Open Form
Progress Report
Name
*
First Name
Last Name
Date
*
MM
DD
YYYY
What improvements have you noticed?
What concerns still exist?
As of today, select the percentage of improvement you have seen in your overall health picture.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Check any of the following you have noticed changes in while under care
Sleep Patterns
Mood
Energy
Immune Health
Digestion
How would you rate your progress?
Excellent
Very good
Fair
No change as of yet
Poor
Have you had an opportunity to do a Google review for our office?
Yes
No
Any question concerning your progress?
Yes
No
Is there anything we can do to improve your experience in our office?
Thank you!
