Application Online

Application for Treatment

Patient Information: 

Name:(last, first, m.i.)  

DOB:  (mm/dd/yy)                         Gender: M F                              Marital status: Single Married Divorced Widowed

Height:       Weight:              Race:  White African American Asian Other         Ethnicity: Non-Hispanic Hispanic

Smoking: Never Occasionaly Daily Former           Amount smoked: None 1-5 6-10 1/2 pack 1 pack 2 packs 3+ packs        Start year:   End year:

Streert Address:  (incl. apt. #):

City:                State:  IL AL AK AZ AR CA CO CT DE FL GA HI ID IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY                  Zip: 

Home phone:      Work phone:       Cell phone:

Email address:

Occupation         Emplotment status: Full time Part time Un-emplod   Title:

Employer:       

Streert Address:  (incl. apt. #):

City:                State:  IL AL AK AZ AR CA CO CT DE FL GA HI ID IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY                  Zip: 

How did you hear about our office:

Emergency contact / Next of kin: 

Name:       Relationship to patient:  Spouse Parent Sibling Child Caregiver Life Partner Emergency Contact Extended Family Friend Guardian Self Other   

Streert Address:  (incl. apt. #):

City:                State:  IL AL AK AZ AR CA CO CT DE FL GA HI ID IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY                  Zip: 

Home phone:      Work phone:       Cell phone:

Past History:

Date of last physical (mm/yy) :     Primary Care Physician:

Have you been treated by a Chiropractor before No Yes    Date of last Chiropractic visit (mm/yy):   

Name of Chiropractor 

Do you use any supports, braces, wraps, heel lifts? No Yes

Past Traumas and Injuries (dates and brief description):

Accidents, Broken bones, Bad falls, Blows to the head or body, Auto accidents, Birth traumas, Other

Past Illnesses or hospitalizations (dates and brief description):

Heart Attack, Stroke, Cancer or Tumors, Other

Past Surgeries (dates and brief description):

Tonsils, Appendix, Hernia, Transfusions, Other 

Family History:

List if Spouse,Mother, Father, Paternal/Maternal Grandparents, Aunts/Uncles, Siblings, Children have any of the following conditions:

Cancer, Heart Problems, High Blood Pressure, Lung Problems, Rheumatoiod arthritis, Lupus, Epilepsy, Diabetes, Chronic Headaches, Chronic Back ache, Stroke, Other 

Social History: Beverages:

Alcohol beverage frequency (per/day week or month):

Caffeine beverages frequency(per/day week or month): 

Rest: Amount of sleep per night:    Sleep on your stomach, back, side

Exercise: Frequency and type:

Diet:  Anything (Fat, Carbs, Sugar, Salt), Balanced,Nutritious, Meat/Potato,Vegan,Vegetarian

Rate job stress on 0-10 scale: 0 1 2 3 4 5 6 7 8 9 10

Rate home / personal life stress on 0-10 scale:  0 1 2 3 4 5 6 7 8 9 10

Use of spare time (hobbies and interests):

Allergies: (Medication, Food, Seasonal, Other)

Immunizations: Childhood (Measles Mumps Rubella), Chicken Pox, Shingles, Flu, Other

Current Medications: (Prescription, Over the Counter, Birth Control, Recreational, Home Remedies, etc.)

Occupational History:

Job requires primarily (sitting,standing,walking,lifting,twisting,jarring jolting forces to the body,vibrating machines)

Does job require head or body to be bent forward, backward to the side or twisted repeatedly or for extended periods? No Yes

Lived or worked in area where there was exposure totoxic metals,gases,fumes,dust,radioactive material,chemicals

Do you have a permanent disability rating?  No Yes     Location where granted: 

                                          Date received:       Rating percentage: