Chiropatic Intake Form (Page 3 of 5) in pdf

For existing patients currently being co-managed within Adjust Your Health, please initial here to give your

consent for the chiropractor to copy your initial intake form & consult with the referring practitioner.

__________.

LIFESTYLE

EXERCISE

WORK

HABITS

STRESS LEVEL

_____ None

____ Sit

____ Smoke(___packs/day)

____ None

_____ Moderate

____ Stand

____ Alcohol(____drinks/wk)

____ Moderate

_____ Daily

____ Light Labour

____ Caffeine(____cups/day)

____ High (Reason:

_____ Heavily

____ Heavy Labour

_____________________)

Please check all that apply to current or previous health history. Although some of the conditions may

seem unrelated to the purpose of your appointment, it is important that the chiropractor have a complete

and clear history of your total health. This may affect your overall diagnosis, treatment plan & possibility

of being accepted for care.

___ Allergy/shots

___ Hernia

___ Polio

___ Anemia

___ Herniated Disc

___ Prostate Problems

___ Anorexia

___ Herpes

___ Prosthesis

___ Appendicitis

___ High Cholesterol

___ Psychiatric care

___ Asthma

___ Influenza

___ Rheumatoid Arthritis

___ Bleeding disorder

___ Kidney Disease

___ Scarlet Fever

___ Bronchitis

___ Liver Disease

___ Small Pox

___ Cataracts

___ Malaria

___ Stroke

___ Chemical dependency

___ Measles

___ Suicide attempt

___ Chicken pox

___ Mental Disorder

___ Thyroid problems

___ Diphtheria

___ Miscarriage

___ Tonsillitis

___ Emphysema

___ Mononucleosis

___ Tuberculosis

___ Fractures

___ Mumps

___ Tumors/growths

___ Glaucoma

___ Osteoporosis

___ Typhoid Fever

___ Goiter

___ Pacemaker

___ Ulcers

___ Gonorrhea

___ Parkinson’s Disease

___ Vaginal infections

___ Gout

___ Pinched nerve

___ Whooping cough

___ Heart Disease

___ Pleurisy

Other:__________________

___ Hepatitis

___ Pneumonia

FAMILY MEDICAL HISTORY

Do you or a family member have a history of the following? Please indicate which family member.

___ Alcoholism

___ Diabetes

___ Learning Disability

___ Allergies

___ Epilepsy

___ Multiple Sclerosis

___ Arthritis

___ Genetic Disease

___ Schizophrenia

___ Asthma

(_________________)

___ Seizures

___ Cancer

___ Hyperactivity

___ Ulcers

___ Cardiovascular Disease

___ High Blood Pressure

___ Venereal Disease

___ Depression

___ HIV

Other:_______________

Chiropatic Intake Form Page 3

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