desmoineschiropractor.net-Welcome Form

Welcome
Please complete this confidential questionnaire. Your answers will help us determine if we can help you. Thank you.
Name*

First NameLast Name
Sex*

MaleFemale
Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Cell Phone Number*
Birth Date*

MonthDayYear
Age*
Marital Status*

MSWD
No. of Children*
Your Occupation*
Employer*
Work Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Spouse*
Spouse’s Cell Number*
Spouse’s Occupation/Company*
Referred By*
Do You Have Health Insurance?*

YesNo
Please list your insurance company(s) *
Spouse’s Insurance Company(s)*
Who is responsible for this account?*
1. What are your major complaints?*
2. What do you think has caused your problem? *
3. How long have you had this condition?*
4. Have you had this or similar conditions before?*

YesNo
Please Describe:*
5. Did this condition start:*

GraduallySuddenly
6. Is this condition getting:*

BetterWorseStays the SameOther
7. Is this condition:*

ConstantComes and goes
8. If you have pain, is it:*

SharpDullBurningAchingThrobbingNumb/TinglingNoneOther
9. Does this condition affect your:*

ArmsLegsNoneOther
10. Is this condition worse at:*

MorningEveningNo Difference
11. What activities or positions aggravate this condition? *
12. What activities or positions relieve this condition? *
13. Is this condition interfering with your:*

WorkSleepDaily RoutineNoneOther
14. Is there anything you have tried yourself to relieve this condition, such as:*

HeatIceRestExercisePillsNoneOther
15. Have you seen any other doctors for this condition?*

YesNo
If so, whom? *
16. If you saw another doctor, did he treat you or prescribe anything for you?*

YesNo
If so, please describe*
17. Have you lost any days from work with this condition?*
18. Have others in your family had this or similar conditions?*

YesNo
If so, please describe*
19. List your accidents or injuries and the years you had them (If not applicable write N/A)*
20. Please list any current medications (If not applicable write N/A)*
21. List all your surgeries and years you had them (If not applicable write N/A): *
22. Have you had any previous chiropractic care?*

YesNo
Please list previous chiropractic care, from whom and when:*
For what problems have you used chiropractic care?*
23. Have you ever had any mental or emotional disorders?*

YesNo
24. What type of service do you desire?*

Temporary relief of this problemMaximum corrective care of this problemMaximum corrective care plus assistance in PREVENTING it from reoccurringMaintenance Care

HAVE YOU EVER:*

	Yes	No	Describe Briefly
Had a CT Scan or MRI Scan?
Had a broken bone?
Been hospitalized?
Taken vitamins or minerals?
Worn cervical collars or back supports?
Had any allergies?

DATE OF LAST: *

	Within 6 months	1-2 years	Over 2 years	Never
Spinal examination
Physical examination
Blood Test
Chest X-ray
Spinal X-ray
Dental X-ray
Urine Test

Please describe anything else you feel would be important for us to know about your current condition or health history (If not applicable... please write N/A)?*
I understand and agree that health and accident policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that this office will help prepare the necessary forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to this office will be credited to my account on receipt. However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and/or treatment, any fees for services rendered me will be immediately due and payable.

I hereby give permission to the doctor to administer treatment and perform such procedures as he may deem necessary in the diagnosis and/or treatment of my condition.
Signature*

Clear
Date*

MonthDayYear
E-mail Address*
example@example.com
IN CASE OF EMERGENCY: (Name of relative or close friend not living in home):
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Name*

First NameLast Name
Date*

MonthDayYear
Mark all the areas of the body where you feel the described sensations. Use the appropriate symbol. Include ALL AFFECTED AREAS.
Type: A = ACHE B = BURNING N = NUMBNESS P = PINS & NEEDLES S = STABBING O = OTHER*
Should be Empty:

	1- Never Had	2- Previously Had	3- Presently Have
Headaches
Low Back Problems
Pain Between Shoulder Blades
Neck Problems
Shoulder Problems
Arm Problems
Wrist/Hand Problems
Hip Problems
Knee Problems
Leg Problems
Foot Problems
Numbness
Stiff/Swollen Joints
Painful Joints
Sore or Weak Muscles
Muscle Twitching
Hernia
Groin Pain
Tailbone Pain

	1- Never Had	2- Previously Had	3- Presently Have
Depression
Fatigue
Paralysis
Dizziness
Fainting
Convulsions
Loss of Sleep
Nervousness
Loss of Concentration

	1- Never Had	2- Previously Had	3- Presently Have
Poor Appetite
Excessive Hunger
Stomach Problems
Difficult Swallowing
Excessive Thirst
Nausea
Vomiting
Gas or Indigestion
Abdominal Pain
Diarrhea
Constipation
Red/Black Stools
Colon Problems
Hemorrhoids
Liver Problems
Gall Bladder Problems

	1- Never Had	2- Previously Had	3- Presently Have
Acne/Skin Eruptions
Psoriasis
Eczema
Bruises Easily
Varicose Veins
Hives

	1- Never Had	2- Previously Had	3- Presently Have
Chest Pain
Poor Circulation
Difficult Breathing
Persistent Cough
Asthma
Coughing Blood
Irregular Heartbeat
Blood Pressure Problems
Heart Problems
Lung Problems
Swelling of Ankles

	1- Never Had	2- Previously Had	3- Presently Have
Enlarged Glands
Eye Pain
Vision Problems
Ear Pain/Noises
Ear Discharge
Hearing Loss
Allergies/Hay Fever
Nose Bleeds
Hoarseness
Sore Gums/Mouth
Sore Throat
Thyroid Problems
Sinus Problems

	1- Never Had	2- Previously Had	3- Presently Have
Prostate Problems
Bladder Problems
Excessive Urination
Kidney Infection/Stones
Painful Urination
Discolored Urine

	1- Never Had	2- Previously Had	3- Presently Have
Alcoholism
Anemia
Appendicitis
Arthritis
Cancer
Chicken Pox
Diabetes
Drug Addiction
Emphysema
Epilepsy
Goiter
Gout
Heart Attack
Heart Disease
Hepatitis
Herpes
HIV Positive/AIDS
Measles
Miscarriage
Multiple Sclerosis
Mumps
Parkinson’s
Pneumonia
Polio
Rheumatic Fever
Rheumatoid Arthritis
Shingles
Stroke
Tuberculosis
Ulcers
Venereal Disease
Whooping Cough

	1- Never Had	2- Previously Had	3- Presently Have
Vaginal Discharge
Cramps
Vaginal Pain
Breast Pain
Lumps on Breast
Painful Menstruation
Excessive Flow
Irregular Cycle
Hot Flashes/Menopause
Infertility
Hysterectomy
Hormone Replacement
Birth Control Medication

Welcome

GENERAL HEALTH HISTORY QUESTIONNAIRE