PERSONAL INFORMATION:

First Name Last Name
Gender      Male Female   Age Birth Date 
Marital Status Single Married Separated Divorced Widowed
Address   
City            State Zip
Home Phone Work Phone
email              Other Phone
Preferred Contact Method Home Phone Work Phone email Other Phone     Best Time to Call Mornings Lunch time Afternoon Evening Any Time
Occupation Employer

HEALTH HISTORY

Are you currently seeing a chiropractor? No Yes

Are you exhausted at the end of each day? No Yes

Do you have trouble relaxing or falling asleep? No Yes

Do you have weight problems? No Yes If yes, please choose: Underweight Overweight Weight control Yo yo dieting

Do you take over-the-counter pain relievers, antacid, tranquilizers, or any other relief-oriented medicines? No Yes How often? Occasionally Weekly 2-3 times a week Daily More than once a day

If yes, please select which one(s) (hold the Ctrl button down and click on as many choices as applicable) Aspirin Ibuprofen (Advil, Motrin, etc.) Tylenol (acetaminophen) Prescription Pain Reliever Antacid (Tums, Rolaids, etc.) Acid Reducer (Tagamet, etc.) Allergy Medicine (Benedryl, other antihistamines) Decongestant (Sudafed, Pseudoephedrine HCL) Laxative

Do you take prescription medications? No Yes

Please specify all prescriptions and doses:

Do you exercise less than 2 times weekly? No Yes

Do you feel that you are a nervous or tense person? No Yes

Do you lose your temper or become angry easily? No Yes

Do you rely on caffeine or sugar stimulants? No Yes

Do you have any discomfort in your back, neck, shoulders, arms or legs? No Yes

Please explain:

Do you have any other health problems of which you are aware? No Yes

Please explain:

Have you had or do you have any of the following symptoms?