Adult Health History

Please use this form for anyone 15 years and older

Name *

Date of Birth *

YYYY

Email Address *

Address

Street Address *

City *

State / Province / Region *

Postal / Zip Code *

Country *

Phone Number *

Who may we thank for referring you to Innate Family Chiropractic? *

Occupation *

Employer Name *

Best Time to Contact *

Number of Children, Names, and Ages *

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. *

General History

List all medications you are taking and why. (Prescription and non-prescription) *

Have you had surgeries or hospitalizations? (Please list all surgeries) *

What do you do for a living? Have you ever had any work related injuries? *

Have you ever had any slips, falls, or auto accidents? *

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) *

Please rank your personal stress levels (1=none, 10=extreme) *

Please rank the following on a scale of 1-5. (1=very poor, 5=excellent)

Eating Habits *

Exercise Habits *

Sleep *

General Health *

Mindset *

Your Goals

At our office we concern ourselves with your health and wellness goals. Please list your goals below.

Physical Goals *

Nutritional/Biochemical Goals *

Mindset/Emotional Goals *

If there is a need for nutritional changes would you like to know?

Yes

Clear selection

If there is a need for specific exercises would you like to know?

Yes

Clear selection

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 *

Today's Date *

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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