Adult Health History
Please use this form for anyone 15 years and older
Name *
Your answer
Date of Birth *
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DD
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Email Address *
Your answer
Address
Street Address *
Your answer
City *
Your answer
State / Province / Region *
Your answer
Postal / Zip Code *
Your answer
Country *
Your answer
Phone Number *
Your answer
Who may we thank for referring you to Innate Family Chiropractic? *
Your answer
Occupation *
Your answer
Employer Name *
Your answer
Best Time to Contact *
Your answer
Number of Children, Names, and Ages *
Your answer
Marital Status *
Current Health Concerns: Please rate the severity of each concern (1 =Mild, 10 Worst Imaginable), When it started, and how often you experience it. *
Your answer
General History
List all medications you are taking and why. (Prescription and non-prescription) *
Your answer
Have you had surgeries or hospitalizations? (Please list all surgeries) *
Your answer
What do you do for a living? Have you ever had any work related injuries? *
Your answer
Have you ever had any slips, falls, or auto accidents? *
Your answer
Please check all that apply even if they do not seem related to your current problem. *
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 *
Your answer
Nutritional/Biochemical Goals *
Your answer
Mindset/Emotional Goals *
Your answer
If there is a need for nutritional changes would you like to know?
If there is a need for specific exercises would you like to know?
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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