Entrance Form
Entrance Information Date:_______________
Name: ___________________________Birth date: _________________Age:_________Phone: Home:________________ Work:_______________ Mobile:________________
Email:_________________________________________
Address:________________________________________________________________
Occupation:______________________________________________________________
Have you seen a Chiropractor before: Y N ; if yes, where?________________________
Name and phone number of medical doctor:____________________________________
Why are you seeking chiropractic care?________________________________________
Major health concerns (if different from above):_________________________________
Required Information: may have implications on how to care for your spine
Have you had any type of surgery? Y/N History of stroke or high blood pressure? Y/N
Are you or could you be pregnant? Y/N Major traumas ie. car accidents, falls, injuries? Y/N
Do you have any implants? (joints, breast) Y/N Have you had any bone fractures? Y/N
Additional Information: may indicate vertebral subluxations in your spine which decrease the function of your nervous system.
Endocrine (e.g. temperature intolerance, diabetes, thyroid conditions)
Eyes/Ears/Nose/Throat (e.g. allergies, dizziness, ringing in ears, nosebleeds)
Gastrointestinal System (e.g. nausea, ulcers, indigestion, abdominal pain, liver disease, pancreatic disorder)
Pulmonary System (e.g. wheezing/asthma, difficulty breathing)
Cardiovascular System (e.g. shortness of breath, chest pain, fainting, edema/swollen ankles, heart disease, high blood pressure)
Urinary System (e.g. mid back/flank pain, kidney disease)
Skin/Hair/Nails (e.g. excessive dryness/perspiration, itching/rashes, change in growth/loss of hair, change in nail texture)
Neurological System (e.g. headaches, seizures/epilepsy, dizziness, numbness/tingling, stroke, disc rupture/herniation, shooting pains)
Musculoskeletal System (e.g. joint pain, stiffness, neck/upper/mid/low back pain, extremity conditions, fractures, injuries (sport, work, auto)
Lifestyle Information: may be a factor in how well you heal/respond to care
Do you eat a healthy diet? Y/N Do you smoke? Y/N
Do you drink pop/soda/soft drinks? Y/N Do you exercise? Y/N
Water consumption per day?__________
Please list any medications:____________________________________________________________
Other: (anything that has not been covered?)
Are you here for symptom relief or for preventative/wellness care? Circle one or both. What are your health goals?
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