Adult Health Intake
Page 1 - Contact Information
Birthdate
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Preferred Name
*
Biological Gender
Male
Female
Email
*
example@example.com
Phone Number (mobile)
*
-
Area Code
Phone Number
1
Single
Married
Other
Kids
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Who may we thank for referring you to us?
What kind of work do you do?
Favorite Hobbies or Interests
Have you been to a chiropractor before?
*
Yes
No
Have you every been under regular/consistent chirorpactic care?
Yes
No
Approximate date of last visit
Doctor's name / city / state
Good results?
Yes
No
Please explain what you liked / disliked about your previous chirorpactic experience(s)
Back
Next
Adult Health Intake
Page 2 - Health History
Check the box that best describes what you'd like us to help you with
*
Overall Health & Well-being
Pain & Symptoms
Why are you here? Why are you wanting our help?
*
Medication(s)
List any past surgeries and dates
List any past accidents / injuries and dates
Please Check All That Apply
Rows
Past
Present
Both
ADHD
2
3
4
Asthma
5
6
7
Allergies
8
9
10
Anxiety
11
12
13
Arm/hand pain
14
15
16
Balance problems
17
18
19
Bed wetting
20
21
22
Brain fog
23
24
25
Chest pain
26
27
28
Cold feet
29
30
31
Cold hands
32
33
34
Cold sweats
35
36
37
Cancer
38
39
40
Depression
41
42
43
Difficulty focusing
44
45
46
Digestion problems
47
48
49
Dizziness
50
51
52
Ear infections
53
54
55
Fatigue
56
57
58
Frequent colds
59
60
61
Frequent illnesses
62
63
64
Fainting
65
66
67
Fever
68
69
70
Headaches
71
72
73
Hip pain
74
75
76
Heart problems
77
78
79
Hot flashes
80
81
82
Irritability
83
84
85
Joint pain
86
87
88
Leg/foot pain
89
90
91
Loss of balance
92
93
94
Low energy/tired
95
96
97
Low back pain
98
99
100
Lights bother eyes
101
102
103
Mid back pain
104
105
106
Migraines
107
108
109
Mood swings
110
111
112
Menstrual pain
113
114
115
Menstrual irregularity
116
117
118
Nausea
119
120
121
Neck pain/stiffness
122
123
124
Numbness in toes
125
126
127
Nervousness
128
129
130
Pin/needles in arms
131
132
133
Pin/needles in legs
134
135
136
Ringing in ears
137
138
139
Sleeping problems
140
141
142
Shoulder pain
143
144
145
Sinus Congestion
146
147
148
Skin conditions
149
150
151
Tension
152
153
154
Urinary problems
155
156
157
Ulcers
158
159
160
Is there anything else regarding your body, health, or past we might need to know to better care for you?
Family Health History
Rows
Children
Siblings
Mother
Father
Grandparents
Caner
161
162
163
164
165
Diabetes
166
167
168
169
170
Heart Disease
171
172
173
174
175
Arthritis
176
177
178
179
180
Please list any other pertinent family health history
Where do you currently see yourself?
*
1
2
3
4
5
6
7
8
9
10
Sickness & Decay (always sick and feeling horrible)
Optimal Health & Performance (feeling and functioning great)
1 is Sickness & Decay (always sick and feeling horrible), 10 is Optimal Health & Performance (feeling and functioning great)
Where do you realistically want to be?
*
1
2
3
4
5
6
7
8
9
10
Sickness & Decay (always sick and feeling horrible)
Optimal Health & Performance (feeling and functioning great)
1 is Sickness & Decay (always sick and feeling horrible), 10 is Optimal Health & Performance (feeling and functioning great)
Back
Next
Adult Health Intake
Page 3 - Health Direction
Are you healthier today than you were 5 years ago?
Yes
No
Not sure
Will you be more healthy in 5 years than you are today?
Yes
No
Not sure
If yes, what will you do to make sure you are?
If no or not sure, what COULD you do to start getting happier and healthier?
What would you like your health to look like 5 years from now?
Back
Next
Adult Health Intake
Page 4 - Terms & Conditions
Initials
*
If you have any images/files you would like us to see, please upload here
Browse Files
Cancel
of
Submit
Back
Next
*** FOR DOCTOR USE ONLY ***
Should be Empty: