Chiropractic Exam Form printable pdf download

Chiropractic

Massage

Acupuncture

Detoxification

Organic Facials

Name _______________________________________________________ E-mail _______________________________________ Date ______________

Address _______________________________________________________________________ City _________________ State ________ Zip __________

H. Phone (_______) ___________________Cell# (______)_______________W. Phone (_______) _________________D.O.B. _____________ Age ______

Referred by ____________________________________________________________ Social Security # _____________________________________________

Occupation ____________________________________________________________ Employer ___________________________________________________

Marital Status

Spouses Name _______________________________________________

Are you pregnant? What week? _____________________________________________ Number of Children and Ages ___________________________________

Have you ever received Chiropractic Care?  Yes  No

 Within 1 year

 Over 1 year Did you have a good experience?  Yes  No

Have you ever received Massage Therapy Before?  Yes  No

 Within 1 year

 Over 1 year Did you have a good experience?  Yes  No

About Your Health

The human body is designed to be healthy. Throughout life, events occur which damage your health expression. This case history will

uncover the layers of damage that have resulted in poor health & brought you here today.

Patient Comment

Chiropractor's

if answer is Yes

Comments

Yes

1. When you were Born 2. When you gave birth



1a. Did your mother complain of a difficult delivery?



1b. Were you born with Forceps or Caesarean?



2a. Number of Vaginal Deliveries?



2b. Number of Caesarean Deliveries?



2c. Pain during past pregnancy? Where?



2d. Complications during past pregnancy?



2e. If pregnant, pain during this pregnancy? Where?



2f. If pregnant, complications during this pregnancy?

2. Growth and Development (1-18 y/o)



Did you have head injuries as a child?



Did you fall out of bed? Fall downstairs?



Chair pulled out when sat down?



Were you picked on by siblings?



Chronic childhood sicknesses?



Childhood car accidents?



Physical Child abuse?



Emotional stress during childhood?



Did you have other traumas? (i.e. sports injuries)



Surgery / stitches?

Current Health Habits



Did/do you smoke? Drink? #per day



Diet (outline typical Breakfast, Lunch, Dinner)



Do you take Multivitamin Omega 3 Probiotic

Other?



Do you exercise?



Do you sleep well? Hours? Side  Back  Stomach



Do you have Physical Stress? (rate on 1 to 10 scale)



Do you have Mental Stress? (rate on 1 to 10 scale)

Chiropractic Exam Form

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