We look forward to meeting you and making your first visit to our office a special one!

Please  PRINT THIS FORM  and bring to the office on your first visit.

HEALTH HISTORY

Name: ___________________________________________________________ DOB: ______ /_______ /______
Address: ______________________________________________________________________________________
City/State: __________________________________________________________ Zip: _____________________
Home Phone: ________________________________ Cell Phone: __________________________________
Work Phone: __________________________ Email: ________________________________________________
Occupation: ______________________________ Employer: ________________________________________
Spouse: _______________________________________________________________________________________
Children (name/age): ________________________________________________________________________

Who Referred You to Us? ____________________________________________________________________
Reason for Consulting Our Office: __________________________________________________________
__________________________________________________________________________________________________
Past Chiropractic Care? YES / NO Date of Last Visit: ________________________________________
Name/Location: _______________________________________________________________________________
Current Medical Care? YES / NO Why? ______________________________________________________
Current Drugs/Medications: _________________________________________________________________

PLEASE CHECK THE ONE CHOICE THAT MOST CLOSELY DESCRIBES YOUR CURRENT GOALS FOR HEALTH/WELLBEING.

I am only concerned about relief of a particular symptom
I am only concerned about relief of a particular symptom, and preventing its return
I want optimum health and wellbeing on every level available to me

WE ACCPT PAYMENT BY CASH, CHECK AND CREDIT CARD
I understand that all services are to be paid in full at the time of service, unless other arrangements have been made and agreed upon in writing.

Signature______________________________________________________ Date__________________

PLEASE TELL US ABOUT ANY STRESS AT YOUR BIRTH:

__ Drugs/medicine/tobacco/alcohol in pregnancy Explain: _________________________________________
__ Labor chemically induced? _________________________________________
__ Forceps/Vacuum Extraction/C-section _________________________________________
__ Premature delivery? _________________________________________
__ Vaccinations? _________________________________________
__ Falls in first year of life? _________________________________________
__ Any health related problems? _________________________________________

PLEASE TELL US ABOUT ANY STRESS ASSOCIATED WITH CHILDHOOD:

__ Any falls or injuries? Explain: _________________________________________
__ Allergy/Asthma or Respiratory problems? _________________________________________
__ Ear infections? _________________________________________
__ Digestive problems? _________________________________________
__ Hyperactivity? _________________________________________
__ Any other health related problems? _________________________________________

PLEASE TELL US ABOUT ANY STRESS UP TO PRESENT:

__Auto Accident or Injury? Explain: _________________________________________
__Work Injury? _________________________________________
__ Sports Injury? _________________________________________
__ Work Stress? _________________________________________
__ Family/Home Stress? _________________________________________
__ Prescription Drug Use? _________________________________________
__ Non-Prescription Drug Use? _________________________________________
__ Ever Hospitalized? _________________________________________
__ Surgery? _________________________________________
__ Any Major Illness? _________________________________________
__ Limited Exercise? _________________________________________
__ Poor Nutrition? _________________________________________

Comments:______________________________________________________________________________________
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