Full Name
Age
Date of birth
Address
City
Postal code
Email
Cell Phone
Occupation
Employer
Marital Status
Single
Married
Divorced
Separated
Widow
Widower
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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
No
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
No
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?
HEALTH INFORMATION AND HEALTH HISTORY
List your hobbies:
What are your habits?
Smoking
Alcohol
Caffeinated Drinks
Exercise
Drug/Substance Abuse (if check discuss with the doctor)
Never
MEDICAL HISTORY
Have you been hospitalized in the past five years
Yes
No
Date (approximate) and Reason
Have you had any serious accidents in the past five years:
Yes
No
Date and Describe
Any surgeries?
In the past 6 months have you suffered from: (Select all that apply, or select normal)
General
Fatigue
Weakness
Weight Change
Loss of sleep
Normal
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Neurological
Headaches
Seizures
Dizziness
Nervousness
Normal
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Vision
Dryness
Redness
Cataract
Glaucoma
Normal
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Nose
Pain
Bleeding
Sinus Trouble
Infections
Normal
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Mouth/Throat
Sores
Bleeding
Enlarged Glands
Tonsillitis
Normal
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Cardiovascular
Hypertension
Sneezing
Wheezing
Chest Pain
Palpitations
Normal
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Gastrointestinal
Diarrhea
Vomiting
Appetite Change
Heartburn
Constipation
Gas
Normal
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Endocrine
Goiter
Diabetes
Heat Intolerance
Cold Intolerance
Normal
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Psychologic
Anxiety
Depression
Memory Loss
Mood Swings
Normal
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Have you ever had any of the following:
Arthritis
Heart Trouble
Pacemaker
Diabetes
Epilepsy
Dislocated Joints
Hay Fever
Asthma
Bone Fracture
Tuberculosis
High Blood Pressure
Serious Injury
Allergies
Low Blood Pressure
Polio
Prostate Trouble
Sinus Trouble
Rheumatic Fever
Kidney Trouble
Scoliosis
Spinal Disease
Cancer
Thyroid Trouble
HIV/Aids
Ulcer
STD
Stroke
Depression
Anxiety
Lyme Disease
Do you have any children (under the age of 21)
What are their ages?
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