PatientName Date Medical Conditions: (Check all that apply to you) Arthritis ⁫Cancer ⁫Diabetes ⁫HeartDisease Hypertension ⁫PsychiatricIllness ⁫SkinDisorder ⁫Stroke Surgeries: (Check all that apply to you) Appendectomy ⁫Cardiovascularprocedure ⁫Cervical JointReplacement ⁫Prostate ⁫Lumbarspine⁫GallBladder Brain ⁫Shoulder ⁫Thoracicspine ⁫Knee CarpalTunnel ⁫Gastro-intestinal ⁫Uro-genital ⁫Hernia Other Allergies: (List any allergies) Social History: (Check all that apply to you) Caffeineuse: occasional never ⁫ ⁫ DrinkAlcohol: occasional ⁫ ⁫often ⁫never Exercise: occasional⁫often never ⁫ ⁫ TobaccoUse: occasional often ⁫ ⁫ ⁫ neverSleep: Hours pernight= Stress Level: High Moderate Low None Family History: all that apply) Arthritis: Parent ⁫ ⁫SiblingCancer:⁫Parent ⁫SiblingDiabetes: ⁫ Parent ⁫SiblingHeart Disease Parent Sibling Hypertension ⁫ ⁫ Parent ⁫ ⁫ SiblingStroke Parent ⁫ ⁫SiblingThyroid ⁫ Parent ⁫SiblingOther
PatientName Date Medical Conditions: (Check all that apply to you) Arthritis ⁫Cancer ⁫Diabetes ⁫HeartDisease Hypertension ⁫PsychiatricIllness ⁫SkinDisorder ⁫Stroke Surgeries: (Check all that apply to you) Appendectomy ⁫Cardiovascularprocedure ⁫Cervical JointReplacement ⁫Prostate ⁫Lumbarspine⁫GallBladder Brain ⁫Shoulder ⁫Thoracicspine ⁫Knee CarpalTunnel ⁫Gastro-intestinal ⁫Uro-genital ⁫Hernia Other Allergies: (List any allergies) Social History: (Check all that apply to you) Caffeineuse: ⁫ occasional ⁫ never DrinkAlcohol: ⁫ occasional ⁫often ⁫never Exercise: ⁫ occasional⁫often ⁫ never TobaccoUse: ⁫ occasional ⁫ often ⁫ neverSleep: Hours pernight= Stress Level: High Moderate Low None Family History: all that apply) Arthritis: ⁫ Parent ⁫SiblingCancer:⁫Parent ⁫SiblingDiabetes: ⁫ Parent ⁫SiblingHeart Disease ⁫ Parent ⁫ Sibling Hypertension ⁫ Parent ⁫ SiblingStroke ⁫ Parent ⁫SiblingThyroid ⁫ Parent ⁫SiblingOther
Chiropractic-New-Patient-Intake-FormsQH-1.docx