*Your privacy is important to us.
We never have and never will disclose any private information to any third party under any circumstances.

Name:
Email Address:
Address :
City:
State:
Phone:
Best time to Contact:	Choose Mornings Afternoon Evening
Age:
Gender:	Select Male Female
Current Weight:
Do you consider yourself:	Select Underweight Overweight Just Right
Unintentional Weight loss or gain of 10lbs. or more in the last 3 months?	Yes     No
Recent changes in your ability to:	See Hear Taste Smell feel hot or cold sensations
How did you hear about our site?	Choose Advetisement Radio Family Friend Co-worker Other If 'Other' please let us know so we might thank them
Prior Chiropractic Care?	Yes    No:
If Yes, When?
Name of Doctor:
Results:	Choose Helped Greatly Helped Some Little Help No Help
Describe Today's Chief Complaint:
Insurance Company:
Are your present problems due to an injury?	Yes: No:
If Yes, Where?	Choose On the Job Auto Accident Personal Injury Other
Have you made a report of your accident?	Choose No Yes, to employer Yes, to Auto Carrier Yes, Workers Comp Other
Are you now or have you ever been Disabled?	Yes     No
If Yes, When?
Have you retained an Attorney?	Yes     No
If Yes, Name and Address
When was your last:
Spinal Exam:
Disc Exam:
X-Ray Exam:
Lab Exam:
Last Physical:
Females: Pap Smear:
Breast Exam:
Habits:
Smoking:	Choose Never Smoked Quit Smoking Smoke less than 1 pack a day More than 1 pack a day More than 2 packs a day
Alcohol:	Choose Never Drink Rarely Drink Week End Drinker Daily Drinker
Coffee:	Choose Never Drink Rarely Drink Cup a Day 2 Cups a day More than 2 Cups
Exercise:	Choose Never Rarely Once a week Every Day
Have you had any of the following Diseases?
Appendicitis - Pneumonia - Rheumatic Fever - Tuberculosis - Whooping Cough
Anemia - Measles - Mumps - Chicken Pox - Diabetes - Cancer - Goiter
Heart Disease - Influenza - Pleurisy - Alcoholism - Venereal Infection - Arthritis
- Polio - Epilepsy - Mental Disorders - Lumbago - Eczema - AIDS
Family History:
Mother:	Diabetes - Heart - Kidney - Cancer
Father:	Diabetes - Heart - Kidney - Cancer
Sisters:	Diabetes - Heart - Kidney - Cancer
Brothers:	Diabetes - Heart - Kidney - Cancer
Signs and Symptoms: A complete history will facilitate care
General Symptoms : Headache: Previously - Presently Fever: Previously - Presently Chills: Previously - Presently Night Sweats: Previously - Presently Fainting: Previously - Presently Dizziness: Previously - Presently Convulsions: Previously - Presently Loss of Sleep: Previously - Presently Fatigue: Previously - Presently Nervousness: Previously - Presently Weight Loss: Previously - Presently Allergy's: Previously - Presently Wheezing: Previously - Presently Neuralgia: Previously - Presently Numbness or pain in arms/legs/hands: Previously - Presently	Gastro-Intestinal: Poor Appetite: Previously - Presently Poor Digestion: Previously - Presently Excessive Hunger: Previously - Presently Belching or Gas: Previously - Presently Nausea: Previously - Presently Vomiting: Previously - Presently Vomiting Blood: Previously - Presently Pain over Stomach: Previously - Presently Constipation: Previously - Presently Diarrhea: Previously - Presently Colon Trouble: Previously - Presently Hemorrhoids: Previously - Presently Liver Trouble: Previously - Presently Jaundice: Previously - Presently Gall Bladder Trouble; Previously - Presently
Eye/Ears/Nose/Throat: Poor Vision: Previously - Presently Crossed Eyes: Previously - Presently Pain in Eyes: Previously - Presently Deafness: Previously - Presently Earache: Previously - Presently Ear Noises: Previously - Presently Ear Discharges: Previously - Presently Nasal Obstruction: Previously - Presently Nose Bleeds: Previously - Presently Sore Throats: Previously - Presently Hoarseness: Previously - Presently Hay Fever: Previously - Presently Asthma: Previously - Presently Frequent Colds: Previously - Presently Enlarged Thyroid: Previously - Presently Tonsillitis: Previously - Presently Sinus Trouble: Previously - Presently	Respiratory: Chronic Cough: Previously - Presently Spitting Blood: Previously - Presently Spitting Phlegm: Previously - Presently Chest Pain: Previously - Presently Difficulty breathing: Previously - Presently Genito-Urninary: Frequent Urination: Previously - Presently Painful Urination: Previously - Presently Blood in Urine: Previously - Presently Kidney Infection: Previously - Presently Bed Wetting: Previously - Presently Prostate Trouble: Previously - Presently Inability to control Urine: Previously - Presently
Muscles & Joints: Weakness: Previously - Presently Twitching: Previously - Presently Stiff Neck: Previously - Presently Backache: Previously - Presently Swollen Joints: Previously - Presently Tremors: Previously - Presently Foot Trouble: Previously - Presently Pain in Tailbone: Previously - Presently Pain Between Shoulders: Previously - Presently Hernia: Previously - Presently Spinal Curvature: Previously - Presently	Cardio-Vascular: Rapid Heart: Previously - Presently Slow Heart: Previously - Presently High Blood Pressure: Previously - Presently Low Blood Pressure: Previously - Presently Pain over Heart: Previously - Presently Heart Trouble: Previously - Presently Swelling Ankles: Previously - Presently Poor Circulation: Previously - Presently Varicose Veins: Previously - Presently Strokes: Previously - Presently
Skin or Allergies: Skin Eruptions: Previously - Presently Itching: Previously - Presently Bruise Easily: Previously - Presently Dryness: Previously - Presently Boils: Previously - Presently Sensitive Skin: Previously - Presently Hives or Allergy: Previously - Presently Eczema: Previously - Presently	FOR WOMEN ONLY: Painful Periods: Previously - Presently Excessive Flow: Previously - Presently Irregular Cycle: Previously - Presently Hot Flashes: Previously - Presently Cramps or Backache: Previously - Presently Miscarriage: Previously - Presently Vaginal Discharge: Previously - Presently Pregnant: Previously - Presently Last Pap: By Whom:
OPERATIONS and PROCEDURES: Vaccinations: Date Tonsillectomy: Date Back Operation: Date Tubes in Ears: Date Appendectomy: Date Female Organs: Date Rectal Surgery: Date Sinus: Date Hernia: Date Thyroid: Date Stomach: Date Other: Date Recent Dental: Date	List any accidents or falls/When: List any Broken bones/When: Ever on Crutches/When: Any Spinal Taps or Injections/When: Ever Knocked Unconscious/When: Ever had a Lapse of Memory/When: Drugs and Medicines: Over the counter, Prescription, and Recreational
Check the following statements that apply:	Occasionally or frequently skip meals Suffer from fatigue Currently overweight Crave sweets or carbohydrates Crave stimulants, such as caffeine or soft drinks Suffer from chronic pain Suffer from headaches
Activity Level – Check Your Current Level of Work or Lifestyle:	Level 1 – Very Light Work: Sitting, standing, driving, reading, computer, etc. Level 2 – Light Work: Light housework, labor, childcare, mechanic, some sitting, etc. Level 3 – Moderate Work: Heavy gardening, housework, labor, no sitting, etc. Level 4 – Heavy Work: Heavy manual labor, construction, digging, etc.
Exercise Level – Check Your Current Level of Exercise:	None Level A – Light Exercise: 1-3 times per week, easy pace, stretching,walking, etc. Level B – Moderate Exercise: 2-3 times per week, moderate pace, some weights, etc. Heavy Exercise - 3-4 times per week, vigorous pace,weights, fast running, etc.
Balance Eating – Check Which Apply:	Mixed food diet (animal and vegetable sources) Vegetarian Vegan Salt Restriction Fat Restriction Starch/carbohydrate restriction The Zone Diet Total calorie restriction
Specific food restrictions of:	dairy wheat eggs soy corn all gluten Other
Servings per day: Fruits (citrus, melons, etc.)
Dark green or deep yellow/orange vegetables
Grains (unprocessed)
Beans, peas, legumes
Dairy, eggs
Meat, poultry, fish
Eating Frequency – Check Which Apply:	Skip breakfast or other meals Three meals/day Two meals/day One meal/day Graze-small frequent meals (how many/day) Generally eat on the run
Exercise Frequency and Schedule – Check Which Apply:	5-7 days per week 3-4 days per week 1-2 days per week 45 min or more duration per workout 30-45 min or more duration per workout Less than 30 min Use of personal trainer Member of fitness club Own exercise equipment Walk: days/week Run, jog, other aerobic: days/week Weight lift: days/week Stretch: days/week Yoga: days/week Other: days/week
Stress Habits – Check Which Apply:
Level of stress you are experiencing on a scale of 1 to 10 (1 being the lowest)
Is your job associated with potentially harmful chemicals, pesticides, radioactivity or solvents:	Yes     No
Do you suffer from insomnia/sleep disorders?	Yes     No
Do you often abruptly awake from sleep?	Yes     No
Do you suffer from depression/mood swings?	Yes     No
Supplement Use Habits – Check Which Apply:	Multivitamin/mineral Vitamin C Vitamin E EPA/DHA GLA (Evening primrose) Calcium, source Magnesium Zinc Minerals, describe Friendly flora (acidophilus) Digestive enzymes Amino acids CoQ10 Antioxidants (lutein, resveritol, etc.) Herbs – teas Herbs – extracts Chinese herbs Ayurvedic herbs Homeopathy Bach flowers Superfoods (bee pollen, phytonutrient blends) Liquid meals (Ensure) Other
Energy – Vitality I’d like to:	Have more energy Have longer endurance Have more motivation Sleep better Be less tired after lunch Feel more vital Regain vitality and vigor of my younger years Get less colds and flu Get rid of allergies Not use so many over the counter drugs Stop using laxatives Be free of pain
Longevity – Life Enrichment I’d like to:	Reduce my risk of degenerative disease Slow down accelerated aging Monitor biomarkers of aging Have less facial wrinkles Maintain a healthier life longer Change from a “treating-illness”orientation to a creating wellness lifestyle
Body Composition – Fat/Muscle I’d like to:	Be stronger Be thinner Be more muscular Burn more body fat Be more flexible Lose weight
Stress Reduction – Mental/Emotional I’d like to:	Be happier Be less depressed Be less moody Be less indecisive Be more focused Think more clearly Improve my memory Learn how to reduce stress Learn how to meditate
Additional Comments: