Patient History Form
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1
2Patient History
Name___________________________________________________________________ Date_______________________________
Address_________________________________________________________________ State_________________ Zip___________
H. Phone (________)_________________________ W. Phone_____________________ Date of Birth___________ Age__________
Referred by________________________________________________Social Security #____________________________________
Occupation________________________________________________Employer__________________________________________
Marital Status S M D W Spouse Name_______________________________________
Number of Children/Ages____________________________________ Spouses Occupation__________________________________
Have you ever received Chiropractic Care? Yes No
Please circle for each of the following:
Patient Comment
Chiropractor’s
If answer is Yes
Comments
1. Regarding your Birth Process:
Was the delivery long/difficult?
Y N _____________________________
_____________________
Forceps or extraction used?
Y N _____________________________
_____________________
Cesarean/ C-Section?
Y N _____________________________
_____________________
Breach/ cephalic?
Y N _____________________________
_____________________
Home birth?
Y N _____________________________
_____________________
Hospital birth?
Y N _____________________________
_____________________
Mother given drugs during delivery?
Y N _____________________________
_____________________
Was labor induced?
Y N _____________________________
_____________________
2. Growth and Development/ Childhood:
Were you breast fed?
Y N _____________________________
_____________________
Health education?
Y N _____________________________
_____________________
Childhood illnesses?
Y N _____________________________
_____________________
Ear infections/ Colic/ Asthma?
Y N _____________________________
_____________________
Attention Deficit?
Y N _____________________________
_____________________
Antibiotics?
Y N _____________________________
_____________________
Drugs, prescription, OTC, recreational?
Y N _____________________________
_____________________
Surgery?
Y N _____________________________
_____________________
Hospitalizations?
Y N _____________________________
_____________________
Sports or other physical activities
Y N _____________________________
_____________________
Injuries during sports?
Y N _____________________________
_____________________
Auto accidents?
Y N _____________________________
_____________________
Did you have other traumas?
Y N _____________________________
_____________________
Did you ever break any bones?
Y N _____________________________
_____________________
3. Current Health Habits:
Did/do you smoke?
Y N _____________________________
_____________________
Did/do you drink alcohol?
Y N _____________________________
_____________________
Diet, do you eat healthy foods?
Y N _____________________________
_____________________
Have you been in accidents/trauma?
Y N _____________________________
_____________________
Have you had surgery?
Y N _____________________________
_____________________
Drugs, prescription, OTC, recreational?
Y N _____________________________
_____________________
Dental problems?
Y N _____________________________
_____________________
Eye problems?
Y N _____________________________
_____________________
Hearing problems?
Y N _____________________________
_____________________
Exercise regularly?
Y N _____________________________
_____________________
Did/do you have occupational stress?
Y N _____________________________
_____________________
Drive? Daily time spent driving
Y N _____________________________
_____________________
Physical stress?
Y N _____________________________
_____________________
Emotional/Mental stress?
Y N _____________________________
_____________________
Hobbies/Sports injuries?
Y N _____________________________
_____________________
Do you sleep well, hours of sleep?
Y N _____________________________
_____________________
Sleeping posture? O side O stomach O back
_____________________________
_____________________
Symptoms and Present State of Health
Present Complaint/Reason for Seeking Care in this Office:
Major_______________________________________________________________________________________________
Pain or Problem started on_______________________________________________________________________________
Pains are:
O Sharp
O Dull/ Ache
O Constant
O Intermittent
O Other______________________
Does this pain shoot, radiate, or travel in your body? Where?____________________________________________________
Are you experiencing numbness or tingling in any area of your body? Where?______________________________________
Since it began, is it:
O Same
O Better
O Worst
What activities aggravate your condition/pain?_______________________________________________________________
What activities lessen your condition/pain?__________________________________________________________________
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Parent category: Medical