Full Name

Date of birth (Month/Day/Year):

Gender

Occupation

Home Address and Phone Number

Employer and Work Phone Number

Family Medical Doctor

Have you had Chiropractic care before? If so, when and by whom?

Spouse's Name and Occupation

Children's Name and Ages

Hobbies

Referred by (please include person's name) Friend/FamilyM.D./D.CInternet/Ad

*If this is a Worker's Comp case please tell us immediately.

Why this form is important:

Our office focuses on your ability to be healthy. Our goals are to first address the issues that brought you to this office, and second, offer the opportunity to improve your health potential in the future. In order to give you the best possible Chiropractic care, we will need to discover any 'stresses' that are placed on your body. Please take the time to fill out this form completely, as each question gives us a clearer picture of your current health status.

Reason for consulting this office

Wellness / Prevention Care - I wish to continue my Chiropractic Wellness Care. Just answer the following questions that apply.

Please describe your current problem, including the effect it has had on your life:

Please describe the character of your pain (check all that apply)

How often are the complaints present?

When is the pain or symptoms worse:

How bad is your pain or ache? (0= no pain, 10 = unbearable pain)

Since your problem began is the pain:

When did your problem begin: (specific date if possible)

Do you sleep on your:

Physical Activity at work:

General physical activity:

How would you rate your stress level:

Do you currently smoke?

Who else have you seen for this condition:   

Please describe any falls, auto accidents or major injuries (include Month/Year, Type of accident):

Please describe any and all past surgery:

Please list ANY and ALL medication (prescription and over the counter): that you are currently taking:

Please Tick Any That Apply: PERSONAL HISTORY:

If Others, please specify:

Please Circle Any That Apply: FAMILY:

If Others, please specify:

Please check all symptoms or areas where you have problems, even if they do not seem related to your current problem.

Do you drink bottled or filtered water: Yes No

Do you belong to a health club or exercises regularly: Yes No

If you remember the details, what was your birth delivery like (eg – breach, c section, long):

Have you had any or all of your childhood vaccinations? All Some

Any reactions to vaccinations?

Please list all supplements and vitamins you take:

How would your rate your health:   

How committed are you to improving your health:   

Do you want to live to be a healthy 85 years old?    Yes No

What is ‘being healthy’ to you (check all that apply)?

What is your goal or expectations with Chiropractic care:

What is your goal or expectations with Chiropractic care:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Signed by Dr. Robert Stewart Pike
Signed On: April 20, 2018

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Document name: Adult Health Profile - Mobile

Unique Document ID: 295095c050e0b87068c3b3ab0a5f721067473a26

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Timestamp	Audit
April 20, 2018 3:47 am EDT	Adult Health Profile - Mobile Uploaded by Dr. Robert Stewart Pike - [email protected] IP 175.158.225.57, 175.158.225.57

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http://pikechiropractic.com/

Audit Trail Serial# 42c6407477dd02f9a489041c74d1f10d