Chiropractic Intake Form - Essential Health Chiropractic (Page 2 of 2) in pdf

Women Only: General Questions

Are you nursing? Y N

Are you taking birth control? Y N

Have you had painful or irregular menstrual cycles? Y N

Are you pregnant? Y N How many weeks? ___________ Any current complications: ___________________________

How many ultrasounds have you had? ___________ Have you had any round ligament pain: Right Side Left Side Both

Who is your OB/Midwife: _____________________________________ What is your estimated due date:____________

Women Only: Past History

Any complications during past pregnancy? Y N Explain: __________________________________________________

Medications taken during pregnancy: _________________________ Cigarettes or alcohol during pregnancy: Y

Complications during delivery? Y N Explain: ____________________________________________________________

Genetic disorders or disabilities:________________________________________________________________________

Review of Systems

Please check if you have had any of the following:

⃝Allergies

⃝Alcoholism

⃝Anemia

⃝Atherosclerosis

⃝Arthritis

⃝Asthma

⃝Back Pain

⃝Breast Lump

⃝Bronchitis

⃝Bruise Easily

⃝Cancer

⃝Chest Pain

⃝Cold Extremities

⃝Constipation

⃝Cramps

⃝Depression

⃝Diabetes

⃝Digestion Problems

⃝Dizziness

⃝Eating Disorder

⃝Excessive Menstruation ⃝Eye Pain/Difficulties

⃝Fatigue

⃝Frequent Urination

⃝Headache

⃝Hemorrhoids

⃝High Blood Pressure

⃝Hot Flashes

⃝Irregular Heart Beat

⃝Irregular Menses

⃝Kidney Infection

⃝Kidney Stones

⃝Loss of Memory

⃝Loss of Balance

⃝Loss of Smell

⃝Loss of Taste

⃝Nosebleeds

⃝Pacemaker

⃝Polio

⃝Poor Posture

⃝Prostate Trouble

⃝Sciatica

⃝Shortness of Breath

⃝Sinus Infection

⃝Sleep Problems/Insomnia ⃝Spinal Curvatures

⃝Stroke

⃝Swelling of Ankles

⃝Swollen Joints

⃝Thyroid Condition

⃝Tuberculosis

⃝Ulcers

⃝Varicose Veins

⃝Venereal Disease

⃝Other

Personal Incident History:

Surgeries: ________________________________________ Illnesses: _________________________________________

Traumas (falls, sprain/strains, broken bones, car accidents):__________________________________________________

Did you seek treatment for this trauma? Y N Where:_____________________________________________________

Hospitalizations:_____________________________________________________________________________________

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Authorization for Treatment

I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify

it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to

this office of chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I

hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the

purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with

my signature for required insurance submissions. I understand and agree that all services rendered to me will be

charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident

insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional

services will become immediately due upon suspension or termination of my care or treatment.

Patient: ________________________________________

Signature: ________________________________________

Print Name

Patient/Legal Guardian

Chiropractic Intake Form - Essential Health Chiropractic Page 2

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