Chiropractor Intake Form Page 3
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5Cardiovascular
No
Respiratory
No
Allergic/Immunologic
No
Past
Present
Past
Present
Past
Present
Poor Circulation
Asthma
Hives
Hypertension
Tuberculosis
Immune Disorder
Aortic Aneurism
Short Breath
HIV/AIDS
Heart Disease
Emphysema
Allergy Shots
Heart Attack
Cold/Flu
Cortisone Use
Chest Pain
Cough
High Cholesterol
Wheezing
Pace Maker
Ear, Nose and Throat
No
Jaw Pain
Eyes
No
Past
Present
Irregular Heartbeat
Past
Present
Difficulty Swallowing
Swelling of legs
Glaucoma
Dizziness
Double Vision
Hearing Loss
Genitourinary
No
Blurred Vision
Sore Throat
Past
Present
Nosebleeds
Kidney Disease
Psychiatric
No
Bleeding Gums
Burning Urination
Past
Present
Sinus Infections
Frequent Urination
Depression
Blood in Urine
Anxiety
Gastrointestinal
No
Kidney Stones
Stress
Past
Present
Lower Side Pain
Gall Bladder Problems
Endocrine
No
Bowel Problems
Neurologic
No
Past
Present
Constipation
Past
Present
Thyroid
Liver Problems
Stroke
Diabetes
Ulcers
Seizures
Hair Loss
Diarrhea
Head Injury
Menopausal
Nausea/Vomiting
Brain Aneurysm
PMS
Bloody Stools
Numbness
Poor Appetite
Severe Headaches
Hematologic
No
Pinched Nerves
Past
Present
Musculoskeletal
No
Parkinson’s
Hepatitis
Past
Present
Carpal Tunnel
Blood Clots
Gout
Vertigo
Cancer
Arthritis
Bruising
Joint Stiffness
Constitutional
No
Bleeding
Muscle Weakness
Past
Present
Fever, Chills
Osteoporosis
Sweating
Broken Bones
Weight Loss/Gain
Varicose Vein
Joints Replaced
Low Energy Level
Neck Pain
Difficulty Sleeping
Low Back Pain
Upper Back Pain
Please list all current medications being taken ________________________________________________
_____________________________________________________________________________________
How are your symptoms changing?
Getting better
Not changing
Getting worse
Are You Pregnant? (Check)
Yes
No
Doctor’s Signature ________________________________________
Patient Name_____________________________________________Date_____________________
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