DC, MD, ND, etc

List any known family illnesses (e.g. hypertension) and the side they originate, (e.g. maternal grandmother).

e.g. Hospitalized for mononucleosis at age 17

Be specific about your workstation, and what you do for the majority of your day e.g. sitting, standing, typing, etc.

List hobbies, sports, and activities outside of work.

If so, what are you taking, and why are you taking it?

e.g. indigestion, IBS, heartburn, etc

e.g. shortness of breath, asthma, etc.

e.g. chronic ear infections, nearsightedness, decreased sense of smell, swollen throat, etc.

e.g. thyroid issues, menopause, adrenal stress, etc

e.g. headaches, Parkinson's, MS, depression, anxiety, etc.

e.g. location, frequency, intensity, triggers, treatments, etc.

e.g. hypertension, history of heart surgery, murmur, etc.

e.g. endometriosis, history of hysterectomy, severe menstrual cramping, frequent urination, prostate problems, etc.

e.g. painful urination, incontinence, constipation, frequent urination

e.g. plantar fasciitis, old shoulder or knee injuries, etc.

e.g. seasonal, medicinal, food, etc

e.g. eczema, rash, etc.

e.g. diabetes, metabolic disorder (syndrome X), etc.

e.g. gym membership, fitbit, garmin, zeo sleep, smartphone apps, etc.

If yes, it is beneficial to have them with you at your visit (don't stress if you can't get them).

Doctors of Chiropractic who use manual therapy techniques are required to advise patients that  there are or may be some risks associated with such treatment. In particular you should note:  a) While rare, some patients may experience short term aggravation of symptoms, rib fractures  or muscle and ligament strains or sprains as a result of manual therapy techniques;  b) There are reported cases of stroke associated with many common neck movements  including adjustments of the upper cervical spine. Present medical and scientific evidence does  not establish a definite cause and effect relationship between upper cervical spine adjustment  and the occurrence of stroke. Furthermore, the apparent association is noted very infrequently.  However, you are being warned of this possible association because stroke sometimes causes  serious neurological impairment and may on rare occasion result in injuries including paralysis.  The possibly of such injuries resulting from upper cervical spinal adjustment is extremely  remote;  c) There is rare reported cases of disc injuries following cervical and lumbar spinal adjustments  or chiropractic treatment.  Chiropractic treatment, including spinal adjustments, has been the subject of government  reports and multi­disciplinary studies conducted over many years and has demonstrated to be  effective treatment for many neck and back conditions involving pain, numbness, muscle spam,  loss of mobility, headaches and other similar symptoms. Chiropractic care contributes to your  overall well being. The risk of injuries or complications from chiropractic treatment is  substantially lower than that associated with many medical or other treatments, medications,  and procedures given for the same treatments. I acknowledge I have discussed, or have had  the opportunity to discuss, with my chiropractor the nature and purpose of chiropractic treatment  in general and my treatment in particular (including spinal adjustment) as well as the contents of  this Consent.  I consent to the chiropractic treatments offered or recommended to me by my chiropractor,  including spinal adjustment. I intend this consent to apply to all my present and future  chiropractic care.