Adobe FormsCentral

It has been a while since your last visit and we want to make sure that we are up to date on your health and wellness needs. Please take a moment to complete this short questionnaire so that we can update our files.

Last name

First name

E-mail

CONTACT INFORMATION

My contact information has not changed since my last visit:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

WHAT IS THE REASON FOR YOUR RETURN AT THE CLINIC?

Where is/are the problem(s)? Please use the lines below to explain.

How long has this been going on?

When did this incident occur?

Is this related to:

Do you have:

Is your pain:

Are your symptoms affected by:

Do your symptoms interfere with:

On a scale of 1-10 (1 = least, 10 = most), please rate the severity of your symptoms

	1	2	3	4	5	6	7	8	9	10

1 is Least, 10 is Most

Do you get headaches?

How often?

Are you receiving care from any other health professionals?

If yes, please name them and their speciality:

GENERAL HEALTH HISTORY

Past injuries can affect present health.

Please check all that apply:

If you answered Yes to any of the above, please describe:

Please list any medications you are taking and the reason for the medication:

Please list any vitamins or supplements that you are taking:

Do you wear orthotics or heal lifts?

Have you ever had X-rays taken of your:

If yes, please tell us where and when these X-rays were taken:

Do you have any other health concerns we should know about?

If Yes, please describe:

Thank you for filling out our Chiropractic Welcome Back Health Questionnaire. We look forward to helping you with your health concerns and overall well-being!