Family Health History Template Page 4
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Spouse Child#1 Child#2 Child #3
Chiropractor’s
Circle all that Apply
Comments
Diet (do you eat healthy foods?)
Y
Y
Y
Y
Y
________________
Have you been in accidents?
Y
Y
Y
Y
Y
________________
Drugs? (Prescriptive or Non-Prescriptive) Y
Y
Y
Y
Y
________________
Have Teeth Problems?
Y
Y
Y
Y
Y
________________
Have Eye Problems?
Y
Y
Y
Y
Y
________________
Have Hearing Problems?
Y
Y
Y
Y
Y
________________
Exercise regularly?
Y
Y
Y
Y
Y
________________
Have sleeping problems? (nightmares)?
Y
Y
Y
Y
Y
________________
Have occupational stress?
Y
Y
Y
Y
Y
________________
Have physical stress?
Y
Y
Y
Y
Y
________________
Have mental stress?
Y
Y
Y
Y
Y
________________
Have hobbies/sports injuries?
Y
Y
Y
Y
Y
________________
Sleeping posture – side–stomach–back _____
_____
_____
_____
_____
________________
Current Health Condition
Present Complaint (be brief) Reason For Your Visit Today
Major _________________________________________________________________________
Pain or Problem started on_________________________________________________________
Pains are:
Sharp
Dull
Constant
Intermittent
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 this condition getting progressively worse? _________________________________________
Other Doctors seen for this condition ________________________________________________
Any home remedies? _____________________________________________________________
Other symptoms:
Headaches
Face Flushed
Light Bothers Eyes
Feet Cold
Neck Pain
Neck Stiff
Loss of Memory
Hands Cold
Sleeping Problems
Pins & Needles in Legs
Ears Ring
Stomach Upset
Back Pain
Pins & Needles in Arms
Fever
Constipation
Nervousness
Numbness in Fingers
Fainting
Loss of Balance
Tension
Numbness in Toes
Cold Sweats
Buzzing in Ear
Irritability
Shortness of Breath
Loss of Smell
Chest Pains
Fatigue
Loss of Taste
Dizziness
Depression
Diarrhea
Have you been under drug and medical care? ________________________________________________________
What medications are you taking? _________________________________________________________________
How Long? _________________ Have you had surgery? ________________ What? ________ When?__________
What side effects have you experienced from the drugs and surgery? ______________________________________
Is there a family history of:
Heart Disease
Arthritis
Cancer
Diabetes
Other _______________
Father’s Side
Mother’s Side
Upon the completion of your first visit, you will receive a Chiropractic Active Life Plan Explanation Sheet to discuss
the different types of Active Life Plans that are available to you. Chiropractic Active Life Plans are designed to help
get you feeling better quickly and to help you and your family be as healthy as possible. Please review the
explanations of the Chiropractic Active Life Plans prior to your Chiropractic Report appointment so you can choose
the level of participation that supports you in reaching all of your health goals.
As a result of my chiropractic care, I would like to
Please check all that apply
Feel better quickly
Have a healthier body by keeping my nerve system healthy
Have a healthier spine
Live a healthier lifestyle
(Continued on Back)
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