Name: Patient #:

Age: Date:

Address:

Home Telephone: Work Phone:

Gender : Male    Female

Social Security # Drivers Lic. #

Date of Birth : Month January February March April May June July August September October November December Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1890 1891 1892 1893 1894 1895 1896 1897 1898 1899 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 Year 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

Occupation/Employer's Name and Address

Marital Status: (Select One) Single Married Separated/Divorced Widowed Domestic Partnership
Spouse's Occupation/Employer's Name and Address

Number of children: (In Canada) Health Card #

Version Code:

Reason for consulting our office: (Please enter the reason for consulting our office.)

Whom may we "Thank" for referring you to our office?

Your Health Profile

Why this form is Important

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. On a daily basis we experience physical, chemical and emotional stresses that can accumulate and result in serious loss of health potential. Most times the effects are gradual: not even felt until they become serious. Answering the following questions will give us a profile of the specific stress you have faced in your lifetime, allowing us to better assess the challenges to your health potential.

The Beginning Years (To age 17)

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.

Your Childhood Years

Adult - (18 to present)

Addressing the Issues That Brought You to the Office

If you have no symptoms or complaints, and are here for wellness services, please check here "Wish to have Chiropractic Wellness Services" and skip to "Family Health Profile." Others need to briefly describe the chief area of complaint, including the effect it has had on your life:

If you are experiencing pain, is it: Sharp Dull Comes and goes Travels Constant Since the problem started, it is... About the same Getting Better Getting Worse

What makes it worse:

Yes, it interferes with: Work Sleep Walking Sitting Hobbies Leisure

Other Doctors seen for this problem (please list):

Chiropractor

Medical Doctor

Other

Please check all symptoms you have ever had, even if they do not seem related to your current problem.

Headaches	Pins and needles in legs	Fainting	Neck Pain
Pins and Needles in arms	Loss of smell	Back Pain	Loss of Balance
Dizziness	Buzzing in Ears	Ringing in Ears	Nervousness
Numbness in fingers	Numbness in toes	Loss of taste	Stomach Upset
Fatigue	Depression	Irritability	Tension
Sleeping Problems	Neck Stiff	Cold Hands	Cold Feet
Diarrhea	Constipation	Fever	Hot Flashes
Cold Sweats	Lights bothers eyes	Problem Urinating	Heartburn
Mood Swings	Menstrual Pain	Menstrual Irregularity	Ulcers

List any medications you are taking

Family Health Profile:

At our office we are not only interested in your health and well-being, but also the health and well-being of your family and loved ones. Please mention below any health conditions or concerns you may have about your:

Children
Spouse
Mother
Father
Brothers
Sisters
Others

Have you ever:

Bought bottled water: Yes No

Belonged to a health club: Yes No

Consumed vitamins or supplements: Yes No

The statements made on the form are accurate to the best of my recollection and I agree to allow this office to examine for further evaluation.

Signature: Date:

Or select File | Print from the top menu to print your completed form. Next call the office to schedule your appointment. Take your completed and printed form to your Rock Chiropractic appointment (512) 238-7625.

© 2000 Chiropractic Leadership Alliance. Form V001-2 To reorder, call 800-285-2001.