Family, Social And Occupational Health History
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2WUNSCH CHIROPRACTIC CLINIC
(Main Office – 530 934-2751) 414 N. Plumas St., Willows, CA 95988
(Satellite Office – 530 865-3735) 750 E. Walker St., Suite C, Orland, CA 95963
FAMILY, SOCIAL AND OCCUPATIONAL HEALTH HISTORY:
PATIENT NAME: _________________________________ DATE: ___________________________
The purpose of this form is to relay your family and social health history to the treating staff. Genetic and environmental variations are known to
Influence individual health. The quality of your care is dependant upon your accuracy and legibility. If you have any questions please notify the staff
immediately.
LIFESTYLE HISTORY:
Do you use tobacco products? NO
YES (Describe): ____________________________________________________
Do you use alcoholic beverages? NO
YES (Describe): __________________________________________________
Do you eat fast food or “junk food”? NO
YES (Describe): ______________________________________________
Do you adhere to any special diet (vegetarian, high protein, diabetic, etc.)? NO YES (Describe):__________________
Do you drink coffee or soda? NO
YES (Describe): ____________________________________________________
Do you use artificial sweeteners or diet products? NO
YES (Describe): ____________________________________
Do you exercise? NO
YES (Describe): ______________________________________________________________
Do you eat at least five servings of fruits and/or vegetables per day? NO
YES
Do you take vitamin/mineral or herbal supplements? NO
YES (Describe):__________________________________
How much water do you drink each day? ______________________________________________________________
How much sleep do you average each night? ___________________________________________________________
How old is your mattress? __________________________________________________________________________
Rate your current stress level: (0 = No stress
5 = Heavy stress)
Circle one 0
1
2
3
4
5
Source of stress: __________________________________________________________________________________
HOBBIES/AVOCATION:
Please list your hobbies: ___________________________________________________________________________
OCCUPATION:
What is your current occupation? ____________________________________________________________________
What other occupations have you had in the past? _______________________________________________________
Do you use a computer? YES NO (If yes, how many hours per day?)_______________________________________
FAMILY HEALTH HISTORY:
Do you have any known family history of the following disorders? (If yes, circle the disorder(s)):
Cancer
Heart Disease
Stroke
Diabetes
High Blood Pressure
Arthritis
Spine Curvature
Back Pain
________________________________________________________________________________________________
If you have children, do they suffer with any health problems? NO
YES (If yes, please list below).
________________________________________________________________________________________________
PATIENT/GUARDIAN SIGNATURE: ________________________________________ DATE:________________
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