Comprehensive Chiropractic Patient History Form

Patient Information

• Full Name: _________________ Date: _________________
• Date of Birth: ______________ Age: __________________
• Address: ________________________________________________
• Phone: _________________ Email: _______________________
• Emergency Contact: _____________ Phone: ________________

Current Complaint

• Primary Complaint: _____________________________________
• Date symptoms began: __________________________________
• Pain intensity (1-10): _____ At worst: _____ At best: _____
• Pain description (check all that apply): □ Sharp □ Dull □ Aching □ Burning □ Throbbing □ Numbness

Medical History

Previous Treatments

• Previous Chiropractic Care? □ Yes □ No
  • If yes, date of last visit: _______________________________
• Other healthcare providers seen for this condition:

  ---

Past Medical History

• Previous injuries/accidents: _____________________________
• Surgeries: ___________________________________________
• Current medications: __________________________________

Family History

□ Diabetes □ Heart Disease □ Cancer □ Arthritis □ Other: _____

Lifestyle Information

• Occupation: _________________________________________
• Physical activity level: □ Sedentary □ Light □ Moderate □ Heavy
• Sleep position: □ Back □ Side □ Stomach
• Hours of sleep per night: _______

Pain Diagram

[Body diagram for marking pain locations]

Consent

I certify that the above information is accurate to the best of my knowledge.

Signature: _________________ Date: _________________