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  • CONFIDENTIAL HEALTH INFORMATION

  • Please allow our staff to photocopy your driver's license and insurance details. All information you supply is confidential. We comply with all federal privacy standards. Please print clearly.

    Shelly Jones, D.C. Chiropractic Wellness Center 5209 Forest Drive, Suite C Columbia, SC 29206 803-771-9990 www.drshellyjones.con doc@drshellyjones.com

  • Demographic Information

  • Today's Date (MM/DD/YYYY)*
     / /
  • Have you consulted a chiropractor before?*
  • Birth Date (MM/DD/YYYY)*
     / /
  • Gender
  • Race*
  • Ethnicity*
  • Smoking Status (age 13 and over)*
  • Format: (000) 000-0000.
  • Marital Status*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • May we contact you at work?
  • Preferred method of contact?*
  • Who carries this policy?
  • Insured's Birth Date (MM/DD/YYYY)
     / /

  • Please describe your Primary Complaint in the space below. Use the Secondary and Additional Complaint boxes if they apply.

  • Primary Complaint

  • And is the result of:*
  • Prior interventions (What have you done to relieve the symptoms?)*

  • Secondary Complaint

  • And is the result of:
  • Prior interventions (What have you done to relieve the symptoms?)

  • Additional Complaint

  • And are the result of:
  • Prior interventions (What have you done to relieve the symptoms?)

  • How does your current condition interfere with your:

  • Review of Systems

    Chiropractic care focuses on the integrity of your nervous system, which controls and regulates your entire body. Please select any condtion that you've had or currently have.

  • Musculoskeletal ~ Currently Have*
  • Musculoskeletal ~ Have Had in the Past*
  • Neurological ~ Currently Have*
  • Neurological ~ Have Had in the Past*
  • Cardiovascular ~ Currently Have*
  • Cardiovascular ~ Have Had in the Past*
  • Respiratory ~ Currently Have*
  • Respiratory ~ Have Had in the Past*
  • Digestive ~ Currently Have*
  • Digestive ~ Have Had in the Past*
  • Sensory ~ Currently Have*
  • Sensory ~ Have Had in the Past*
  • Skin ~ Currently Have*
  • Skin ~ Have Had in the Past*
  • Endocrine ~ Currently Have*
  • Endocrine ~ Have Had in the Past*
  • Genitourinary ~ Currently Have*
  • Genitourinary ~ Have Had in the Past*
  • Constitutional ~ Currently Have*
  • Constitutional ~ Have Had in the Past*

  • Health History

    Please identify your past health history, including accidents, injuries, illnesses, and treatments. Please complete each section fully.

  • Illnesses

  • Check the illnesses you have had in the past.*
  • Check the illnesses you have now.*

  • Allergies

  • Are you allergic to any medications?*

  • Operations

  • Surgical interventions, which may or may not have included hospitalization*

  • Treatments

  • Check the ones you've received in the PAST*
  • Check the ones you are CURRENTLY receiving*

  • Injuries

  • Have you ever...*

  • Family History

    Some health issues are hereditary. Tell Dr. Jones about the health of your immediate family members.

  • Mother

  • State of Health
  • Cause of death

  • Father

  • State of Health
  • Cause of death

  • Sister 1

  • State of Health
  • Cause of death

  • Sister 2

  • State of Health
  • Cause of death

  • Brother 1

  • State of Health
  • Cause of death

  • Brother 2

  • State of Health
  • Cause of death

  • Additional Entry

  • State of Health
  • Cause of death

  • Social History

    Tell Dr. Jones about your health habits and stress levels.

  • Alcohol use
  • Coffee use
  • Tobacco use
  • Exercising
  • Pain relievers
  • Soft drinks
  • Water intake
  • Prayer or meditation?
  • Job pressure/stress?
  • Financial peace?
  • Vaccinated?
  • Mercury fillings?
  • Recreational drugs?

  • Activities of Daily Living

    How does this condition currently interfere with your life and ability to function?

  • Sitting*
  • Rising out of chair*
  • Standing*
  • Walking*
  • Lying down*
  • Bending over*
  • Climbing stairs*
  • Using a computer*
  • Getting in/out of car*
  • Driving a car*
  • Looking over shoulder*
  • Caring for family*
  • Grocery shopping*
  • Household chores*
  • Lifting objects*
  • Reaching overhead*
  • Showering or bathing*
  • Dressing myself*
  • Love life*
  • Getting to sleep*
  • Staying asleep*
  • Concentrating*
  • Exercising*
  • Yard work*
  • Describe your typical eating habits:

  • Acknledgements

    To set clear expectations, improve communications, and help you get the best results in the shortest amount of time, please read each statement and initial your agreement.

  • Date of last menstrual period (MM/DD/YYYY)
     / /
  • Date
     - -
  •  
  • Should be Empty: