Medical questionnaire

This lets us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know! so you can be completed in the convenience of your own home or office.

Your Full Name (required)

Gender FemaleMale
Your Email (required)

Date of Birth: year month day
Address:
Phone:
Occupation:
1) Major complaint
2) How long have you had this condition ?
3) What describes the nature of your symptons ?
4) How often do you experience your symptoms ?
5) How are your symptoms changing ?
6) Was the injury, accident related ? NoAuto accidentWork accidentOthers If yes, when ?
7) Have you ever been allergic to medication or food? NoYes
8) Previous Chiropractic care ? YesNo
9) When was your last visit ?

10) Any accidents, injuries or surgeries ?
11) Are you currently taking any medication ? NoYes
List all drugs, vitamins you now take (prescription and non prescription).

12) Have you ever been allergic to medication or food ? YesNo
13) What are your health goals ?
14) Please mark if you have had any of these symptoms in the last 12mo. :
Fractured bonesAuto AccidentsOther accidents, fallsArthritisDiabetesConvulsions, epilepsySkin problemsCancerFrequent colds, fluDepressedIrritableAnemiaAllergy, sinusUnder stressEating disordersTrouble sleepingTrouble concentratingLearning disabilityMood ChangesNeck pain or stiffnessNumbness/tingling, pain in arm, hands, fingersJaw pain or clicks (TMJD)Difficulty in excessive standing, sitting, riding, bending, lifting, twistingShoulder painDizzinessRinging in earsHearing lossBlurred or double visionUpper back pain, stiffnessMid back pain, stiffnessPain with cough, sneezeHip painHeadachesNumbness, tingling, pain in buttocks, leg, feet, toesFoot troubleChest pain, asthmaHeart problemsStrokeHigh/low blood pressureVaricose veinsLiver troubleGall bladder troubleDigestive problemsUlcersHemorrhoidsProstate problemsImpotenceKidney troubleMenstrual problems (PMS)Pregnant (NOW)Bed wettingEar infectionsAIDS, HIV
Visual Analogue Scale for pain
15) Please select the number that best describes the your pain scale from no pain (0) to worst possible pain (10).

Questions for women only:
Are you pregnant or do you have a possibility of pregnancy ? NoYes
Are you presently breastfeeding ? NoYes

Any Comments

Security Check
Please enter words below.

* Automatic Security Check

* Please check acceptance box for confirmation.
Acceptance    

ページ上部へ戻る