Chiropractic Intake Form

Is it worse in the morning or at night?

worse in the morning

worse at night

worse at random times

the same all the time

Do you ever have numbness, tingling or pain in the arms, hands, legs or feet? If so where?

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How often do you feel the pain and how long does it last?

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Please list any heath care professionals you have seen in the past?

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Do you smoke?:

Yes

Do you drink alcohol?

Yes

If yes, how many drinks do you have per week?

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Do you Exercise?

Yes

If yes, how many hours do your exercise per week?

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How is your quality of sleep?

excellent - I sleep all the way through the night and I have no trouble falling asleep or staying asleep during the night

ok- I sleep most of the way through the night, I may wake up to go to the bathroom once or twice during the night, I have no trouble falling asleep

terrible- I have difficulty falling asleep and/or staying asleep. I wake up frequently or I wake up in the middle of the night and can't go back to sleep. I feel tired the next day.

How is your diet?

great - I eat lots of fresh vegetables and whole grains and I stay away from sugar

ok - I eat some vegetables but not every day and/or I may eat some fast food 1-2 times a week and/or I eat sweets at 2 meals a day

terrible - I do not eat fresh vegetables every day and/or I eat out a lot during the week, and/or my diet mostly consists of processed food, and/or I eat foods that are made with refined white flour like white bread or pasta, and/or my diet consists of mostly chips, chicken fingers, pizza rolls and taquitos.

Do you get any dizziness?

YES

Do you have any heart, lung or stomach problems?

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Are you looking for temporary relief or do you want to fully correct the cause of your problem?

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Why?

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What activities or hobbies have you been unable to do because of your problem?

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Do you have any family history of:

Diabetes

Stroke

Heart disease

Cancer

neck pain

lower back pain

upper mid back pain

rib pain

shoulder pain

elbow pain

wrist pain

hip pain

knee pain

ankle/foot pain

TMJ (jaw pain)

Headaches

Sinusitis

Hearing Problems

Ringing in the Ears

Vertigo/Dizziness

Eye Problems

Vision Problems

Nose Problems

Sore Throat

Voice Changes

Chest Pain

Palpitations

Blood Pressure Issues

Asthma

Allergies

Insomnia

Night Sweats

Lung Problems

Shortness of Breath

Skin problems

Bruise Easily

Nausea

Heartburn

Poor Appetite

Loss of taste

Bloating

Numbness

Fainting

Anxiety

Depression

Belching/Gas

Diarrhea

Constipation

Abdominal Pain

Liver Problems □

Kidney Problems

Frequent Urination

Urinary Tract Infections

Painful Urination

Prostate Trouble

Incontinence

Hemmorhoids

Muscle Cramps

Diabetes

Nosebleeds

Stiff Joints and muscles

Low Energy

Poor Appetite

Scoliosis

Poor Posture

depression

anxiety

bipolar

Other mental health issue

Congested Breasts

Lumps in Breasts

Cramps or Backache

Irregular Cycle

Excessive Menstrual Flow

Endometriosis

Hot Flashes

Menopausal Symptoms

Irregular Periods

Painful Periods

Absent Periods

Is there any chance you could be pregnant?

YES

If YES, how far along are you and when is your due date?

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heart disease

stroke

diabetes

cancer

Have you ever been to a Chiropractor before?

YES

If so, when was your most recent visit?

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Many times, when dysfunction is occurring in the body, symptoms are the last thing to show up and the first thing to go away

True

False

When a bone moves out of places and affects nervous system function, that is called a Subluxation.

True

False

Stress is what causes subluxations

True

False

The 3 main types of stress are Physical, Emotional and Chemical.

True

False

The only thing a Chiropractor does is detect and correct subluxations. Anything else is not considered Chiropractic.

True

False

When a Chiropractor moves a bone back into proper alignment, this is called an adjustment.

True

False

ANYONE can benefit from Chiropractic care.

True

False

Stress causes subluxations and most people are under some kind of stress, it is recommended that everyone gets their spine checked every 1-2 weeks for subluxations to make sure the nervous system is functioning correctly.

True

False

Anything that is good for your health requires Time and Repetition. Chiropractic requires Time and Repetition.

True

False

When joints are subluxated, degenerative change is occurring at that joint until that subluxation is corrected.

True

False

Informed Consent To Care (Review Required)

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Consent For Transmission Of Protected Health Information by Non-Secure Means (Review Required)

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Consent To Initiate Care And Disclosure Of No Insurance Billing (Review Required)

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Work Injury/Automobile Injury Notice and Purpose of an Adjustment Disclosure (Review Required)

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