Full Name

Age

Date of birth

Address

City

Postal code

Cell Phone

Occupation

Employer

Marital Status

How did you hear about us? Who may we thank for referring you?

HEALTH CARE PRACTICIONER HISTORY

Current Primary Care Physician

Physician Location

Have you ever received chiropractic care?

Yes

Name of D.C.

Last visit to this chiropractor:

Reason for Leaving:

REASONS FOR SEEKING CHIROPRACTIC CARE

What concerns do you feel Lakeville Chiropractic can address for you?

For Women

Are you pregnant?

Yes

If x-rays are recommended your signature is required (below) to indicate that you are not pregnant.

Clear

Signed on this Date

If pregnant, Due Date

OBGYN or Midwife

ADULT CONSULTATION HISTORY

Main complaint (if you have no complaint, simply write "Wellness", and skip to the next page)

Any other complaints

How long have you suffered with this problem?

Do you know how this problem began?

What have you tried to do to get rid of this problem that DID NOT work?

Have you become discouraged about handling this problem?

When your problem is at its worst, how does it make you feel?

How does the problem interfere with the following areas of your life?

Work

Family

Hobbies

Daily Activities

Does this problem cause stress for you?

What do you do that makes this problem worse

What gives you some temporary relief?

How much older does this make you feel?

Are you currently taking any vitamins or supplements? (Please list the amount and frequency) (i.e. 5mg once a day, etc.)

Are you currently taking any medications? (Please include regularly used over the counter medications and list the dosage and frequency) (i.e. 5mg once a day, etc.)

Is there any other health information you would like use to know?

PLEASE READ AND SIGN BELOW

The information I have provided on this form, is true and accurate to the best of my knowledge. I give Dr. Michael P. Griffin permission to render care to me today. This initial visit includes a health history/consultation, chiropractic exam/evaluation. I also give my consent to have the doctor order any x-rays that he deems appropriate, and any initial care that is determined to be clinically necessary and mutually agreed upon.

Signature

Clear

Today’s Date

Signature of Parent (for minor):

Clear

Today’s Date