rilascio chiropractic
rilascio.com
Confidential Patient Information
Name_____________________________ □ Male □ Female Age _______ Date of Birth ___________________ Home Phone __________________ Cell Phone ___________________ Work Phone ____________________________ Address ______________________________________ City ______________ State _______ Zip Code ____________ E-mail _______________________________________ Social Security Number ______________________________ Occupation ______________________________ Employer _______________________________________________
Married □ Spouse (Name ____________________ ) Single □ Divorced □ Widowed □
Children’s Names/ Ages _______________ _______________ _______________ _______________
Whom may we thank for referring you to our office? _____________________________________________________ Emergency Contact Person _____________________________ Phone Number ________________________________
Have you had Chiropractic care before? □ No □ Yes- When/Where? ___________________________________
If you are leaving area for extended periods, when are you leaving: _________ Returning ____________________
HOW CAN WE SERVE YOU? □ I have no complaints. I am here for a wellness checkup.
Subluxations (spinal misalignments) cause most of the unwanted health conditions people suffer from every day. Subluxations affect your nervous system, which affects your health.
1. What is your 1st health concern? _________________________________ First occurrence date:___________
Subluxations irritate nerve fibers causing various sensations. Which describes your concern?
□ Sharp □ Dull □ Throbbing □ Burning □ Aching □ Stabbing □ Numbness -
Depending on the type and degree of subluxation, nerve pressure can be constant or occasional.
How often is your concern? □ Constant □ Occasional
2. What is your 2nd health concern? ______________________________ First occurrence date: ___________
Subluxations irritate nerve fibers causing various sensations. Which describes your concern?
□ Sharp □ Dull □ Throbbing □ Burning □ Aching □ Stabbing □ Numbness -
Depending on the type and degree of subluxation, nerve pressure can be constant or occasional.
How often is your concern? □ Constant □ Occasional
Please List All Medications: (prescription And over the counter)
(Blood Pressure, Pain, Anti-Depressants, Hormonal, Ritalin, Botox, Antibiotics, Aspirin, Tylenol, Advil, etc.)
1. _______________ for _____________ 2. _______________ for ______________ 3. _______________ for ___________
4. _______________ for _____________ 5. _______________ for ______________ 6. _______________ for ___________
Please List All Surgeries/hospitalization: (including dental/cosmetic)
1. _______________ for _____________ 2. _______________ for ______________ 3. _______________ for ___________ 4. _______________ for _____________ 5. _______________ for ______________ 6. _______________ for ___________
Please List All Accidents/injuries: (including car/bike/falls)
_____________________ ____________________ ______________________
✓Check any of the following that apply:
Neurological
❏ headaches / migraines
❏ numbness Where? ________
❏ irritable
❏ fatigue
❏ nervousness
❏ restless leg
❏ seizures / tremors
❏ anxiety / ptsd
❏ depression
❏ fibromyalgia
❏ sleeping problems
❏ allergies
❏ dizziness / loss of balance
❏ concussion / spinal injury
❏ other ________________
Cardio-Vascular
❏ high/low blood pressure
❏ rapid/slow heart beat
❏ swelling of ankles
❏ chest pain
❏ heart attack/stroke
❏ other __________________
Eyes, Ears, Nose & Throat
❏ frequent colds/sinus infections
❏ thyroid trouble
❏ asthma
❏ ringing in ears/ear aches
❏ vision problems
❏ other __________________
Gastro Intestinal
❏ unexplained weight loss/gain
❏ diarrhea / constipation
❏ colon trouble / ibs
❏ loss of bowel control
❏ difficult digestion
❏ acid reflux / heart burn / gerd
❏ other _______________
Genito-Urinary
❏ bed wetting
❏ frequent urination
❏ loss of urine control
❏ kidney infection/stones
❏ bladder infection/cyst
❏ prostate troubles
❏ other _______________
Women Only
❏ menstruation
❏ infertility
❏ pregnant due date ________
❏ other ____________________
Respiratory
❏ asthma
❏ chronic cough
❏ sleep apnea
❏ other ___________
Do You Presently Have Cancer
❏ cancer
❏ heart disease
❏ diabetes
❏ other ____________
Dr. Schuyler Du Bourdieu | Dr. Giovanna Du Bourdieu
we listen. we care. we get results.
805 899 3333 . connect@rilascio.com . 1221 state street #200 santa barbara, ca