YOUR HEALTH HISTORY

Name:_______________________________________ Date:______________

Address: _________________City: __________________Zip:_________

Home Phone: ________________________Work________________________ Phone_________________________________

DOB:_______________ Referred by:________________________________

Social Security#________________________Occupation_________________

Marital Status:     S    M    L/W     D    W       Spouse Name:_______________________________

Past Chiropractic Care? ____________________When/Where_______________

Why are you seeking care?___________________________________________

Is this related to an auto accident or work injury?   YES     NO

The human body is designed to be healthy.  Throughout life events occur which damage your health expression.  This form will help to uncover the layers of damage, primarily to your nervous system, which have resulted in less than optimum health.

THE PRACTICE OF CHIROPRACTIC IS BASED ON THE LOCATION AND THE REDUCTION OF VERTEBRAL SUBLUXATIONS.  ANY STRESS TO WHICH YOUR BODY CANNOT ADAPT CAUSES THESE SUBLUXATIONS.   THESE STRESSES MAY BE PHYSICAL, CHEMICAL, OR EMOTIONAL IN NATURE.

Following your chiropractic examination, we will outline a course of care to allow your body to begin correcting these layers of damage so you can recover your natural innate health potential.

YES   NO                                                                                            COMMENTS

                                    1.DURING PREGNANCY, DID YOUR MOTHER

___  ___          Experience any physical trauma (falls, injuries)                ________________________

___  ___          Have any ultrasound/dop-tones (how many)                     _______________________

___  ___          Eat a well balanced diet                                                  _______________________

___  ___          Smoke tobacco                                                              _______________________

___  ___          Drink alcohol                                                                  _______________________

___  ___          Take ANY drugs or medicines                                        _______________________

___  ___          Have any emotional trauma/difficulty                               _______________________

                                    2.YOUR BIRTH PROCESS    

___  ___          Hospital birth                                                                  _______________________

___  ___          Was labor induced                                                          _______________________

___  ___          Were any drugs given during labor                                  _______________________

___  ___          Were you in breech position                                            _______________________

___  ___          Was labor “difficult”                                                       _______________________

___  ___          Were forceps or suction used                                          _______________________

___  ___          Was there any “pulling” by the doctor                              _______________________

3.EARLY DEVELOPMENT  

___   ___         Did you ever fall from a height before walking        ____________________________

___   ___         Were you a “head banger” or “rocker”                   ____________________________

___   ___         Any other injuries or falls                                    ____________________________

___   ___         Were you in a “walker” or door swing                 ____________________________

___   ___         Were you ever tossed in the air or shaken                        ____________________________

___   ___         Were you nursed (how long)                               ____________________________

___   ___         Were you vaccinated (some/all)                          ____________________________

___   ___         Were you given any drugs/medication                  ____________________________

___   ___         Any illnesses up to age 5                                     ____________________________

YES         NO                                                                                                          COMMENTS

                                                1.HAVE YOU HAD PHYSICAL TRAUMA

___   ___         Injuries during play or sports                               ____________________________

___   ___         Accident or job related injury                               ____________________________

___   ___         Any surgery or medical procedures                     ____________________________

___   ___         Exercise problems or injuries                              ____________________________

                        Exercise:   regular   irregular   rarely

___   ___         other physical trauma                                         ____________________________

                                    2.CHEMICAL OR EMOTIONAL TRAUMA

___   ___         Did/do you smoke/use tobacco                            ____________________________

___   ___         Did/do you drink alcohol              regular   irregular   rarely   never

___   ___         Did/do you use non-medical/prescription drugs

                                                                                    regular    irregular   rarely   never

___   ___         Did/do you use “over the counter drugs”              ____________________________

                                                                                    regular    irregular   rarely   never

___   ___         Do you drink fluoridated water   

___   ___         Do you have occupational stress                          ____________________________

___   ___         Did/do you have family/home stress                     ____________________________

___   ___         Did/do you have any sleeping difficulty                ____________________________

                                    posture:    side   stomach   back  

___   ___         Did/do you experience any emotional stress         ____________________________

Are you currently under drug/medical care?_______ For?_____________________

Are there any drugs/medications you are currently taking?_______________________________

Are you interested in a print-out of their side-effects if available?_________________________

Chiropractic provides three types of care.  The first is the initial intensive care that allows for the reduction or correction of the most recent layers of spinal and neurological damage (vertebral subluxation complex).  Next begins reconstructive care that allows time for the body to correct and heal the years of damage that occurred before the need for chiropractic care became apparent.  Finally, chiropractic offers a genuine approach to wellness care.  This allows you to do the best you can by keeping you as free of the effects of vertebral subluxation as possible.  All these options will be explained to during your report of findings.

WE ACCEPT CASH OR PERSONAL CHECK