ADULT SPINAL HEALTH FORM
Please complete the following information:
Name
*
First Name
Middle Initial
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Choose One:
*
Please Select
Minor
Married
Divorced
Separated
Widowed
Single
Do you have Medicare?
*
Please Select
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Cellular Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Carrier
*
Ok to receive text messages?
*
Please Select
Yes
No
Email
*
example@example.com
Ok to receive email messages?
*
Please Select
Yes
No
Birthdate
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
Sex
*
Please Select
Female
Male
Whom may we thank for your referral?
Occupation
*
Employer's Name
*
Employer's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Height
*
Spouse/Guardian's Name
Spouse's Birthday
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Children's Names and Ages
Back
Next
List your major complaints in order of severity and please indicate how long you have had this complaint
*
Do you have any difficulty with any of the following?
*
Headaches
Throat trouble
Depression
Shooting head pains
Infections
Anxiety
Sinus trouble
Thyroid trouble
Stress
Loss of smell-taste
Sleeping trouble
Dizziness/vertigo
Hay fever/ Allergies
Facial pain or palsy
Neck pain
Asthma
Loss of memory
TMJ/jaw issues
Cancer
Chronic fatigue
Fainting or seizures
Loss of balance
Ringing of ears
Hearing difficulty
Eye/vision trouble
Neck muscle spasm
Tightness in shoulder muscles
Pain in shoulders & arms
Pins & needles in arms & hands
Cold hands
Chest pains or rib pains
Shortness of breath
Carpal tunnel syndrome
Fibromyalgia
Heart palpitation or heart trouble
Upper back pain
Mid back pain
Shoulder pain
Diabetes
High blood pressure
Low blood pressure
Liver trouble
Anemia
Acid reflux or ulcers
Abdominal pain
Stomach trouble
Indigestion
Nerves, nervousness
Inner tension
Irritability-moodiness
Prostate trouble
Bladder problems
Gall bladder problems
Kidney trouble
Buttocks pain
Low Back pain
Constipation
Diarrhea
Painful Menstruation
Irregular Menstruation
Miscarriage
Arthritis
Tailbone/sacrum pain
Painful joints
Swollen joints
Hip pain
Slipped disc
Pinched nerve in back
Pins & needles in legs
Swollen ankles
Cold feet
Numbness in legs
Knee pain
Groin pain
Pain in legs
Pain in feet
List all auto accidents you have been in:
*
List any concussions you have had in your life:
*
What's the most significant trauma you have ever had to your body?
*
List all surgeries or fractures and when:
*
List all medications and what they’re for:
*
Other doctors seen for this condition:
*
Do you wear orthotics?
*
Please Select
Yes
No
Do you wear a heel lift?
*
Please Select
Yes
No
If so, right or left and how long?
Previous chiropractic care?
*
Please Select
Yes
No
If yes, when?
What are your expectations from receiving and maintaining your spinal correction at 1st Place Chiropractic?
*
Are you willing to be an active patient in the improvement of your health?
*
Please Select
Yes
No
As a result of my chiropractic care, I would like to: (please check all that apply)
*
Feel better quickly
Have a healthier spine
Have a healthier body by keeping my nerve system healthy
Live a healthier lifestyle
What are your top 3 health goals?
*
Signature
*
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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