Chiropractor Intake Form Page 2
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5How did you hear about our office? ___________________________________________________
Medical Conditions: (Circle all that apply to you)
Arthritis
Cancer
Diabetes
Heart Disease
Hypertension
Psychiatric Illness
Skin Disorder
Stroke
Other ______________
Fibromyalgia
Asthma
Osteoporosis
Surgeries: (Circle all that apply to you)
Appendectomy
Cardiovascular procedure Cervical spine
Hysterectomy
Joint Replacement
Prostate
Lumbar spine
Gall Bladder
Brain
Shoulder
Thoracic spine
Knee
Carpal Tunnel
Gastro-intestinal
Uro-genital
Hernia
Breast Augmentation
Other ______________
Allergies: (Circle all that apply to you)
Mold
Seasonal
Milk or Lactose
Animal
Chemical ___________
Sulfites
Wheat/Glutens
Other _________
Social History: (Circle all that apply to you)
Caffeine use:
occasional
often
never
Drink Alcohol:
occasional
often
never
Exercise:
occasional
often
never
Drink Water: <64 oz/day
>64 oz/day
never
Cigarettes:
<1 pack/day
>1 pack/day
never
Sleep:
<8 hours/night
>=8 hours/night
Insomnia
Other ________________
Family History: (Circle all that apply)
Arthritis:
Parent
Sibling
Cancer:
Parent
Sibling
Diabetes:
Parent
Sibling
Heart Disease Parent
Sibling
Hypertension Parent
Sibling
Stroke
Parent
Sibling
Thyroid
Parent
Sibling
Other _________________
Occupational Activities: (Circle one that best describes your job description)
Administration
Business Owner
Clerical/Secretary Computer User
Heavy Equipment operator Daycare/Childcare
Construction
Health Care
Food Service Industry
Medium Manual Labor
Manufacturing
Home Services
Heavy Manual Labor
Light Manual Labor
Executive/Legal
Housekeeper
Other ________________
Doctor’s Signature ________________________________________
Patient Name__________________________________________________Date___________________
Review of Systems – (Check box if you have had trouble with any of the following)
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