Last Name                                         First Name                                           Middle                  
Address                                                                                                                                          
City                                               State                     Zip                                      
Date of Birth                                     SS#                                              
Home Phone #                                       Work #                                                       
Marital Status:   S   M   W   D
    Spouse                                                                  
     Spouse's DOB                                                     
     Spouse's Employer                                           
Insurance Company                                                          
Group #                                                     Policy #                                                                   
Occupation                                                                    
Referred by:                                                                   
Emergency Contact                                                                          
Patient Signature                                                                             

What is your main concern?                                                                                               
                                                                                                                                              
Other concerns?                                                                                                                   
How long have you had this condition?                                                                              
Have you had this or similar condition in the past?                                                          
Did your accident occur while at work?   Yes/No  When?                                                  
Is this condition getting progressively worse?   Yes/No     Consistent/Comes & Goes
Is this a new or old injury? (circle one)
Was it treated before?  Yes/No
If yes, what was done?                                                                                                         
                                                                                                                                              
Name of Doctors.                                                                                                                 
Have you ever had surgery?  Yes/No
List surgeries.                                                                                                                      
Have you ever been hospitalized?  Yes/No
Have you ever had Chiropractic care before?  Yes/No
Name of Doctor.                                                                                                                  
Last time you had spinal x-rays or other x-rays?                                                              
Medications you now take.                                                                                                 
From birth to present please list by date and describe.
-Car Accidents                                                                                                                     
                                                                                                                                             
-Falls/Injuries (including sports)                                                                                         
                                                                                                                                             
-Other