Please complete this questionnaire and bring it with you to your appointment.

Name:  Date:

Date of Birth:   Age:        Dominant Hand:  Right   Left

Height:  Weight: Your Occupation:

Family or private doctor(s):  

Who made this appointment for you?:  Self   Physician - name:

History of Present Illness: What specifically brings you to see the doctor today? Please describe your symptoms (e.g. right leg pain and back pain, etc.)

When did your symptoms begin?  

List all spine pain and spine surgeries you’ve had. Include surgeon and date where appropriate:

SURGERY/ SPINE PAIN                                SURGEON                                      APPROXIMATE DATE

Please list all other doctors, chiropractors or other providers whom you’ve seen for this problem. Please list tests and procedures performed.

DATE                          DOCTOR                                TESTS/PROCEDURES                     LOCATION

Is your problem related to an accident or injury?   Yes  No   Date of Injury:  

Is it work related?   Yes   No      Date of Injury:  

Is a lawsuit planned or in progress?   Yes   No   Name of attorney:  

Have you had physical therapy?   Yes   No   Location:  

  Starting:  Ending:

Have you had chiropractic treatment?   Yes   No   By whom?:

Have you worn any type of brace or support?   Yes   No   Type:  

Do you have a cardiac pacemaker?     Yes     No  

Medications (If needed use a separate sheet of paper):

Please list all medications/drugs that you are currently taking – List the dosages and frequency.

Please include any regular and occasional medications, as well as over-the-counter medications.

Do you have any medication allergies or any other allergies?    Yes    No

Please list those allergies and the type of reaction you had. (E.g. rash, stomach upset, etc.)

Habits:

Do you/have you smoked cigarettes?     Yes     No     How many packs/day?:  

For how many years?:             When did you quit?:

Do you use alcohol?     Yes   No   How much/how often?: 

Do you use “street” drugs?          Yes     No      Type?: 

Please list all other surgeries you have had. Include surgeon and date.

SURGERY                                                                  SURGEON                           APPROXIMATE DATE

Please list all hospitalizations, treating doctors and dates hospitalized. (I.e. pneumonia, Flu, West Nile, or other illnesses)

REASON FOR HOSPITALIZATION                           DOCTOR                             APPROXIMATE DATE

Social History:

Where do you live? (City/State name)  

Are you?:  married   single    widowed    divorced

Are you employed?   Yes   No,  where do you work?

When was your last day of work?

Are you retired?   Yes    No,  where did you work?  

Family History:

Please list family members, living and deceased, their ages, and any major health problems?

Father:   living, age       deceased          health problems?:

Mother:   living, age       deceased          health problems?:

Sister(s):         # living         # deceased     health problems?:

Brother(s):       # living         # deceased    health problems?:  

Daughter(s):    # living         # deceased     health problems?:    

Son(s):            # living        # deceased      health problems?:

REVIEW OF SYSTEMS:

Please check any of the following medical problems that you are currently or have previously been treated for. Please provide an explanation in the space below: