Family Health History Template Page 3

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Mix Family Chiropractic
Personal and Family Health History
Referred By __________________________________
Name _______________________________________
Social Security # _______________________________
Date _________________
Occupation ___________________________________
Address _____________________________________
Employer ____________________________________
City ____________________ State ____ Zip ________
Marital Status
S
M
D
W
Phone: (H) _______________ (W) ________________
Spouse’s Name _______________________________
E-mail _______________________________________
Spouse’s Date of Birth___________________________
Date of Birth _______________ (Age ______)
Number of Children and Ages
Previous Chiropractic Care?
Name ____________________________
Age _____ Yes___ No___ Reason _____________________________
Name ____________________________
Age _____ Yes___ No___ Reason _____________________________
Name ____________________________
Age _____ Yes___ No___ Reason _____________________________
Name ____________________________
Age _____ Yes___ No___ Reason _____________________________
You deserve to be healthy. Life is a miracle and so are you. When you were created, you were given all the blue-
prints, intelligence, tools, and systems to live an active healthy life. Unfortunately, your health can be interfered with
through accidents and challenges that cause a disruption to your health expression. Through your examination and
through your lifetime involvement in chiropractic care, we will work to remove these interferences to your natural
health expression so that you can live the quality of life you deserve.
Patient
Spouse Child#1 Child#2 Child #3
Chiropractor’s
Circle all that Apply
Comments
1. Was Your Birth Traumatic?
Long Delivery?
Y
Y
Y
Y
Y
________________
Difficult Delivery?
Y
Y
Y
Y
Y
________________
Forceps?
Y
Y
Y
Y
Y
________________
Caesarian?
Y
Y
Y
Y
Y
________________
Breach/cephalic?
Y
Y
Y
Y
Y
________________
Home birth?
Y
Y
Y
Y
Y
________________
Mother given drugs during delivery?
Y
Y
Y
Y
Y
________________
Induced Labor?
Y
Y
Y
Y
Y
________________
2. Growth and Development
Did you ever once...
Learn to care for your spine?
Y
Y
Y
Y
Y
________________
Fall out of bed?
Y
Y
Y
Y
Y
________________
Bang your head?
Y
Y
Y
Y
Y
________________
Breastfeed?
Y
Y
Y
Y
Y
________________
Childhood sickness?
Y
Y
Y
Y
Y
________________
Have any Accidents?
Y
Y
Y
Y
Y
________________
Have Surgery?
Y
Y
Y
Y
Y
________________
Take Drugs?
Y
Y
Y
Y
Y
________________
Fall while learning to walk?
Y
Y
Y
Y
Y
________________
Bullied by your siblings?
Y
Y
Y
Y
Y
________________
Child abuse
Y
Y
Y
Y
Y
________________
Spanking?
Y
Y
Y
Y
Y
________________
Pulled ear/chin?
Y
Y
Y
Y
Y
________________
Other
Y
Y
Y
Y
Y
________________
Chair pulled out when sitting?
Y
Y
Y
Y
Y
________________
Fall down the stairs?
Y
Y
Y
Y
Y
________________
Pulled by your arm?
Y
Y
Y
Y
Y
________________
Experience other traumas?
Y
Y
Y
Y
Y
________________
3. Current Health Habits
Did/do you...
Smoke?
Y
Y
Y
Y
Y
________________
Drink?
Y
Y
Y
Y
Y
________________
(Continued on Back)

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