Welcome to Central Baldwin Chiropractic Center……. Name: ____________________________________________________ Date: ______________ Last
Telephone: _______________________________________Social Security #: ______________________ Home
How would you like to receive your appointment reminders (circle one)? TEXT EMAIL TELEPHONE Email Address: ________________________________________________________________________ Date of Birth: _________________ Age: ____
Sex: MALE / FEMALE
Marital Status: M D W
Employer: _____________________________________ Occupation: ____________________________ Spouse Name: ___________________________________ Telephone: ___________________________ Whom may we thank for referring you to our office?_________________________________________ Describe your pain (circle all that apply): Sharp Dull Diffuse Achy Numb Tingly Sharp with motion Stabbing with motion Electric-like with motion
Shooting Stiff Shooting with motion Other: ___________________________
Indicate on the drawing below where you have pain/symptoms How often do you experience your symptoms? Constantly (76-100% of the time) Frequently (51-75% of the time) Occasionally (26-50% of the time) Intermittently (1-25% of the time) How are your symptoms changing with time? Getting better Staying the same Getting worse
Using a scale of 0-10 (10 being the worst), how would you rate your problem? 1 2 3 4 5 6 7 8 9 10
How much has the problem interfered with your work (circle one)? Not at all A little bit Moderately Quite a bit Extremely How much has the problem interfered with your social activities (circle one)? Not at all A little bit Moderately Quite a bit Extremely Page 1 of 3 Please continue on the back of this page.
Who else have you seen for your problem? Chiropractor Neurologist ER Physician Orthopedist Massage Therapist Physical Therapist
Primary Care Physician Other: ________________ No one
How long have you had this problem? ______________________________ How do you think this problem began? _____________________________ Do you consider this problem severe? YES
YES, AT TIMES
What aggravates your problem? _________________________________________________________ What alleviates your problem? ___________________________________________________________ What concerns you most about this problem?_______________________________________________ HEIGHT _________________ WEIGHT ________________ Rate your overall health:
What type of exercise do you do?
Indicate if you have any immediate family members with any of the following: Rheumatoid Arthritis Diabetes Lupus Heart Problems Cancer ALS Please check “PAST” and/or “PRESENT” if you suffer or have suffered from the following condition(s): PAST PRESENT PAST PRESENT PAST PRESENT Headaches High Blood Pressure Diabetes Neck Pain Heat Attack Excessive Thirst Upper Back Pain Chest Pains Frequent Urination Mid Back Pain Stroke Smoking/Tobacco Low Back Pain Angina Drug/Alcohol Dependence Shoulder Pain Kidney Stones Allergies Upper Arm Pain Kidney Disorder Depression Wrist Pain Bladder Infection Systemic Lupus Hand Pain Painful Urination Epilepsy Hip Pain Loss of Bladder Control Dermatitis/Eczema/Rash Upper Leg Pain Prostate Problems HIV / AIDS Knee Pain Abnormal weight Gain/Loss Ankle / Foot Pain Loss of Appetite FOR FEMALES ONLY Jaw Pain Abdominal Pain Birth Control Pills Joint Pain/Stiffness Ulcer Hormonal Replacement Arthritis Hepatitis Pregnancy Rheumatoid Arthritis Liver/Gall Bladder Disorder Cancer General Fatigue Tumor Loss of Muscular Coordination Asthma Visual Disturbances Chronic Sinusitis Dizziness Other: ___________ Page 2 of 3 Please continue on the next page.
List all prescription and over-the-counter medication you are currently taking: ________________________________________
List all supplements you are currently taking: ________________________________________
Have you ever been hospitalized (circle one)? YES NO If yes, why? ___________________________________________________________________________ List all surgical procedures you have had: ________________________________________
What activities do you do at home / work (circle all that apply)? SIT Most of the day Half the day A little of the day
STAND Most of the day Half the day A little of the day
COMPUTER WORK Most of the day Half the day A little of the day
ON THE PHONE Most of the day Half the day A little of the day
What activities do you do outside of work? ________________________________________
Have you ever been treated by a Chiropractor (circle one)? YES NO If yes, how long ago? _________________ Results (circle one): GREAT GOOD FAIR MIXED POOR Have you had significant past trauma (circle one)?
Anything else pertinent to your visit today? ________________________________________________ I affirm that the information I have given is correct to the best of my knowledge, and that it is my responsibility to inform this office of any changes in my medical status. __________________________________________________________ Signature
The power that made the body, can heal the body ~ B.J. Palmer
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