HEALTH CARE PROVIDERS Have you had previous Chiropractic Care? If yes, have you been adjusted? PATIENT SYMPTOMS Describe your chief complaint Is the complaint worse at a certain time of day? Has the complaint affected your daily activities? Has the complaint affected your ability to sleep? Has the complaint affected your appetite? Has this happened before? Have you had to miss work? Does the weather affect your complaint? What makes your complaint feel worse? If yes, what time? If yes, how? If yes, how? If yes, how? If yes, when? If yes, when was your last day of work? If yes, how? What makes your complaint feel better? How does your complaint interfere with the following areas of your life? MEDICAL HISTORY Have you been involved in an Auto/ATV accident? Do you experience frequent illnesses/colds/flus? Any hospitalizations or surgeries? Are you on any type of medication? Do you have any environmental allergies? Do you have any food allergies? If yes, what? Please list all - If yes, what? If yes, what? If yes, what do you smoke and how much per week? If yes, how much per week? If yes, how many drinks per week?
Famiy Histoy of (check all that apply)
WOMEN'S HEALTH Have you had any previous pregnancies? Are you currently breastfeeding or pumping for bottle feeding? Are you currently taking birth control? Are you using other means of contraception? Do you have a regular menstrual period? Are you currently trying to conceive? Do you have painful periods? Any pelvic conditions (PCOS, Endometriosis, Fibroids, Hysterectomy)? Are you currently undergoing Hormone Replacement Therapy? QUALITY OF LIFE Current level of negative stress? How well do you cope with stress? Current nutritional intake? FAMILY CONCERNS Submit