Patient Information Form

PERSONAL INFORMATION

Introductory Patient Information

First Name *

Last Name *

Date *

Street Address *

Date Of Birth *

Address Line 2

City *

State *

Zip Code *

Home Phone Number *

Cell Phone Number *

Email address *

Martial Status *

Spouse name *

List Children and their ages:

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How did you hear about us? *

Who can we thank for your referral?

Who is your primary physician and their phone number? *

Have you or your family experienced any major life changes? *

Yes

No

If yes, please comment

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Have you experienced any major losses in life? *

Yes

No

If so, please comment

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CURRENT HEALTH CONDITION

Reason for visit: *

When and how did your problem begin? *

Have you received care for this problem? If yes, please explain. *

What makes the problem better and/or worse? *

Is the condition getting worse/improving/same? *

Rate your CURRENT pain level: (0= no pain, 10= emergency room pain) *

Rate your AVERAGE pain level: (0= no pain, 10= emergency room pain) *

FOR WOMEN ONLY

Are you currently pregnant or suspect you could be pregnant? *

If yes, expected due date? *

Are you currently nursing? *

TRAUMAS: PHYSICAL INJURY HISTORY

Have you ever had any significant falls, surgeries, accidents or injuries? If yes please explain. *

Have you ever been hospitalized? If yes, please explain. *

Have you had any notable childhood injuries? If yes, please explain. *

Have you been involved in any car accidents? If yes, please explain and describe. *

LIFESTYLE HISTORY

How much exercise do you perform? *

What types of exercises do you usually perform? *

How do you normally sleep? (check all that apply) *

Back

Side

Stomach

Other

Do you usually wake up: (please check all the apply) *

Refreshed

Tired

Stiff

Other

Do you commute to work *

How many minutes per day do you commute to work? *

How many hours per day do you typically spend sitting (work included)? *

TOXINS: CHEMICAL & ENVIRONMENTAL EXPOSURE

Please rate your CONSUMPTION for each of the following: (1=never, 5=high) *

	1	2	3	4	5
Alcohol:	1	2	3	4	5
Water:	1	2	3	4	5
Sugar:	1	2	3	4	5
Dairy:	1	2	3	4	5
Gluten:	1	2	3	4	5
Caffeine:	1	2	3	4	5
Processed Foods:	1	2	3	4	5
Sweeteners:	1	2	3	4	5
Sugary Drinks:	1	2	3	4	5
Tobacco:	1	2	3	4	5
Recreational Drugs:	1	2	3	4	5
Fast Food:	1	2	3	4	5

Please list any allergies: *

Please list any drugs/medications/herbs/vitamins/supplements/other that you are taking and what you are taking them for? *

THOUGHTS: EMOTIONAL STRESS

Please rate your STRESS for each: (1=none, 5=high) *

	1	2	3	4	5
Home:	1	2	3	4	5
Work:	1	2	3	4	5
Life:	1	2	3	4	5
Financial:	1	2	3	4	5
Health:	1	2	3	4	5
Family:	1	2	3	4	5
Other:	1	2	3	4	5

ESTABLISHING HEALTH GOALS

PERSONAL MESSAGE

I have read something interesting: “The definition of insanity is to keep doing the same thing and expecting different results”. If you keep following the same course of treatment you have been following will your results really change? Have you ever wondered if you are on the right path to achieving optimal health? Sometimes it requires taking a new and improved road to reach your destination.

Most people I ask tell me they’re made the decision to change. But how many people have truly decided to change? Very few! Why? Because there is a big difference between deciding something and having “reasons” to actually do it.

When you have made a decision to make a change and you know your reasons, you create an internal power that can propel you to achieving health and wellness.

What do you hope to achieve with your visit here with us? *