Adult Health History
Please use this form for anyone 15 years and older
* Required
Name
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Your answer
Date of Birth
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MM
/
DD
/
YYYY
Email Address
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Your answer
Address
Street Address
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Your answer
City
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Your answer
State / Province / Region
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Your answer
Postal / Zip Code
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Your answer
Country
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Your answer
Phone Number
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Your answer
Who may we thank for referring you to Innate Family Chiropractic?
*
Your answer
Occupation
*
Your answer
Employer Name
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Your answer
Best Time to Contact
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Your answer
Number of Children, Names, and Ages
*
Your answer
Marital Status
*
Single
Married
Divorced
Widowed
Current Health Concerns: Please rate the severity of each concern (1 =Mild, 10 Worst Imaginable), When it started, and how often you experience it.
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Your answer
General History
List all medications you are taking and why. (Prescription and non-prescription)
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Your answer
Have you had surgeries or hospitalizations? (Please list all surgeries)
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Your answer
What do you do for a living? Have you ever had any work related injuries?
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Your answer
Have you ever had any slips, falls, or auto accidents?
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Your answer
Please check all that apply even if they do not seem related to your current problem.
*
Headaches
Dizziness
Numbness in Fingers
Pins & Needles in Arms
Pins & Needles in Legs
Fatigue
Sleeping Issues
Diarrhea
Cold Sweats
Mood Swings
Loss of Smell
Buzzing in Ears
Numbness in Toes
Depression
Stiff Neck
Constipation
Light Bothers Eyes
Menstrual Pain
Fainting
Back Pain
Ringing in Ears
Loss of Taste
Irritability
Cold Hands
Fever
Urinary Problems
Menstrual Irregularity
Neck Pain
Loss of Balance
Nervousness
Stomach Upset
Tension
Cold Feet
Hot Flashes
Heartburn
Ulcers
Required
Please rank your occupational stress levels (1=none, 10=extreme)
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1
2
3
4
5
6
7
8
9
10
Please rank your personal stress levels (1=none, 10=extreme)
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1
2
3
4
5
6
7
8
9
10
Please rank the following on a scale of 1-5. (1=very poor, 5=excellent)
Eating Habits
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1
2
3
4
5
Exercise Habits
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1
2
3
4
5
Sleep
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1
2
3
4
5
General Health
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1
2
3
4
5
Mindset
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1
2
3
4
5
Your Goals
At our office we concern ourselves with your health and wellness goals. Please list your goals below.
Physical Goals
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Your answer
Nutritional/Biochemical Goals
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Your answer
Mindset/Emotional Goals
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Your answer
If there is a need for nutritional changes would you like to know?
Yes
No
If there is a need for specific exercises would you like to know?
Yes
No
Confirmation
I consent to a professional and complete chiropractic examination and to any radiographic examination that the doctor deems necessary. I understand that any fee for service rendered is due at the time of service and cannot be deferred to a later date.
Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Thank You!
Thanks for filling out this form. It is your first step to achieving wellness! Please hit the submit button to send it to our team.
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