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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