Chiropractic Health Questionnaire

Camp Hill Family Chiropractic, PC

 

Name                                                                Home Phone                            ____     Cell Phone                               _____

 

Address                                                                                    City, State, Zip                                                            _____

 

Birth Date                                Age     ___ SS#                                    _______ E-mail Address                                     _____

 

Occupation                               Employer                                                         _ Work Phone                                      _____

 

Marital Status:  S  M  W  D  Sep   Mates Name                             Children (Ages)                                                _____            _____

           

1.       Most patients are referred to our office by a caring family member or friend. What made you decide to visit our office?

Family Member / Friend Name                                              Phone Call  /  Phone Book  /  Web  /  Event  /  Health Screening

 

2.       Research shows that your spine should be checked regularly.  Have you ever been to a Chiropractor before?   Yes   No

If yes, When?                                         Who?                                        _____                              # of Visits       _____

 

3.       When was your last complete spinal examination?  Never  Date      _____  Last X-ray of your spine?  Never  Date             _____

 

4.       Spinal misalignments can cause decay & degeneration; make you feel like you need to twist, stretch or crack your neck/ back.

Do you ever feel the need to crack or pop your neck or lower spine?                      Yes       No

Do you ever hear noises when you move your head & neck?                                 Yes       No

 

5.       Poor posture leads to poor health and often indicates a spinal problem.

How would you rate your posture?         Poor     1     2     3     4     5     6     7     8     9     10    Excellent

 

6.       Stress can cause or accelerate spinal damage. Rate your stress level.   Low    1     2     3     4     5     6     7     8     9     10  High

 

      7.    What is your Chief Complaint today?                                                                   _______  Mark your areas of pain w/ an X

 

  What activity were you doing?                                         When did it begin? ____________

 

Is your condition?      Mild    Moderate    Severe   Rate your symptom: _____ /10 (Severe)

 

Daily Activities Restricted:  (Circle)   Work    Sleep    Daily Routine     Recreation

 

Movements that are Painful to Perform: (Circle)    Sit     Stand     Walk    Bending    Lying

 

What Treatment have you already received for this condition?  Medications ____________

___ Surgery ___ Physical Therapy ___ Chiropractic ___ None ___ Other         ______________

 

Work Activity:  ___ Sit   ___ Stand ___ Light Labor ___ Heavy Labor ___ Repetitive Motions        Exercise?  Yes    No

 

Habits: ___ Smoke ___ Alcohol ___ Coffee/Caffeine Drinks ___ High Stress Level ___ Vitamins  ___ Nutritional Supplements  

 

      8.   List any other health symptoms or health problems.

1.                                                  ___ 2.                                              ______   3.                                              _____

           

9.       Prescription medications may cause various side effects.  They hide the severity & hinder the body’s ability to heal.

What medications are you currently taking and for what condition?

 

1. _______________      __ For?                          _______  2.                               ___ For?                        ____________

 

3.                                  __ For?                          _______  4.                               ___ For?                        ____________

 

10.   Auto and work–related injuries can cause serious spinal problems.

Is this visit related to a(n):    Auto Accident  or  Work Injury?       No     Yes  

  Date of Incident                                    _____

 

11.   Spinal health is especially important during pregnancy.  Is there any chance that you are pregnant?              Yes      No

           

12.   If the doctor feels that Chiropractic will help you, are you willing to follow his recommendations?                Yes      No

 

CONSENT FOR TREATMENT

My signature implies consent for treatment. (If under 18, a parent or guardian’s signature is required). The above information is true and accurate to the best of my knowledge.  This permission will authorize this office to release any information pertinent to my condition or case to any insurance company, adjustor, or attorney involved in this case and hereby releases this office consequence thereof.

 

Signature                                                                                            Date