Form – Patient Health History Form 1 "*" indicates required fields PERSONAL INFORMATIONName*Social Security*Mobile Number*Email Address* Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Age*Date of birth* MM slash DD slash YYYY Sex* Male Female Marital StatusChildren?OccupationEmployerWork NumberEmployer Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of SpouseOccupationWork NumberEmergency ContactPhone NumberHow did you hear about us?(Please write in name of person or event)HEALTH HISTORYPurpose of this appointmentIs this condition getting progressively worse? Yes No Comes and Goes How long has it been since you really felt good?What positions or activities affect your condition?What do you believe is wrong with you?Other doctors seen for this condition:Do you take any vitamins?Select oneYesNoDo you think you might need vitamins or minerals?Select oneYesNoAre you wearing heel lifts?Select oneSole LiftsInner SolesArch SupportsDo you have tingling or numbness inSelect oneShouldersArmsElbowsHandsHipsLegsKneesFeetHave you been treated for any health conditions by a physician in the last year?Select oneYesNoDescribe:Serious illness?What operations have you had?Date of last physical: MM slash DD slash YYYY Female: Are you pregnant? Yes No What medications or drugs are you taking (including birth control pills)?Date of last spinal x-ray: MM slash DD slash YYYY Have you ever been under chiropractic care?Select oneYesNoDoctor’s name:Additional information you would like to tell us:Have you ever suffered from: Allergies Dizziness Fatigue Headaches Loss of Sleep Ulcers Nervousness Arthritis Bursitis Foot Trouble Low Back Pain Frequent Urination Kidney Infections Kidney Stones Prostate Trouble Cramps or Backache Excessive Menstural Flow Hot Flashes Irregular Cycle Drug Addiction Depression Numbness Polio Sciatica Spinal Curvature Swollen Joints Diarrhea Difficult Digestion Hemorroids Immune Deficiency Syndrome Deafness Ear Noises Thyroid Eye Pain Falling Vision Vulnerable Disease Bed Wetting Lumps in Breast Alcoholism Nausea Tuberculosis Bruise Easily Hay Fever Nosebleeds Asthma Colds Sinus Infections High Blood Pressure Pain Over Heart Poor Circulation Rapid Heart Beat Slow Heart Beat Anemia Stroke Chest Pain Difficult Breathing Pleurisy Spitting Swelling of Ankles Cancer Diabetes Habits Heavy Moderate Light None Dairy Alcohol Drugs Exercise Coffee Sleep Appetite Sodas Tea Sweets Water Tobacco Billing InformationIs this condition due to injury or sickness arising out of your employment?Select oneYesNoDate symptom appeared or accident happened: MM slash DD slash YYYY Same or similar condition? Yes No Have you lost any days from work?Select oneYesNoName of health insurance:Phone numberPayment is expected in full at time of visitName of person responsible for paymentI clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment.Patient's signatureDate MM slash DD slash YYYY Parent or guardian authorizing careDate MM slash DD slash YYYY CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Please do not submit any Protected Health Information (PHI).