Please Fill Out the Adult Patient Questionnaire Below:

Confidential Patient Information

Sex:

Marital Status:

Number of Children:

Current Health Conditions

How did the problem start?

Is this condition:

Your Health Goals

Chiropractic History

What would you like to gain from your chiropractic care?

Have you ever visited a chiropractor?

-If yes, what is their name?

What is their specialty?

Do you have any health concerns for any other family members?

TRAUMAS: Physical Injury History

Ever had any significant falls, surgeries or other injuries as an adult?

-If yes, please explain:

Notable childhood injuries?

-If yes, please explain:

Youth or college sports?

-If yes, please explain:

Any auto accidents?

-If yes, please explain:

Exercise frequently?

What type of exercise?

How do you normally sleep?

Do you wake up:

Do you commute to work?

-If yes, how many minutes per day?

TOXINS: Chemical and Environment Exposure

Please rate your CONSUMPTION for each:

0 being the lowest consumption and 5 being the highest consumption

Alcohol

Processed Food

Water

Artificial Sweetner

Sugar

Sugary Drinks

Dairy

Cigarettes

Gluten

Recreational Drugs

THOUGHTS: Emotional Stress and Challenges

Please rate your STRESS for each:

0 being the lowest stress and 5 being the highest stress

Home

Money

Work

Health

Life

Family

Acknowledgement & Consent