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