Chiropractic Exam Form (Page 2 of 2) in pdf

Yes

Injuries as an Adult



Have you been in car accidents as an adult?



Have you had surgery and organs removed/replaced?



Sports injuries as an adult?



Falls as an adult?



Other?

PLEASE MARK YOUR AREA(s) OF PAIN

Have you been under drug and medical care?

What medications are you taking?

Have you had an Xray/MRI in past 3 years?

Have you had blood testing/regular checkup?

Is there a family history of:

 Heart Disease  Cancer  Diabetes

 Arthritis  Other_________________

Symptom(s) that brought you to us?

Years of continuing damage eventually show up as acute or chronic symptoms.

Present Complaint (be brief)

Major

Pain or Problem started?

Previous Episodes?

 Sharp

 Dull

 Constant

 Intermittent

Pains are:

What activities aggravate your condition/pain?

What activities lessen your condition/pain?

Is condition worse during certain times of the day?

Is this condition interfering with work?

Sleep?

Routine?

Other?

Is condition getting progressively worse?

Other Doctors seen for this condition

Other symptoms:

 Headaches

 Pins & Needles in Legs

 Fainting/Nausea

 Neck Pain/Tension

 Pins & Needles in Arms

 Difficulty Urinating

 Sleeping Problems

 Numbness in Fingers

 Osteoporosis/Osteopenia

 Back Pain/Tension

 Numbness in Toes

 Disc Problems

 Pain w/ sneeze or cough

 Shortness of Breath

 Insomnia

 Pain w/ standing (from sitting)

 Fatigue/low energy

 Allergies

 Weakness

 Depression/Anxiety

 Stomach Upset

 Chest Pains

 Diabetes/frequent urination

 Constipation

 Dizziness

 Cancer/sudden weight loss

 Diarrhea

 Heart Conditions

 Blood Clots

 Loss of Balance

 Circulatory Conditions

 Infections

 Other_________________

About Us:

We believe integrative health is the way to do that.

We want to give people more miracles that become the standard of care.

Chiropractic Exam Form Page 2

Related Articles

Related forms

Related Categories