Adult Personal Health History

1
Your Name* This field is required.Please use legal spelling of first and last name
First Name
Last Name
2
Preferred name/nickname
3
Gender* This field is required.
Male
Female
4
Date of Birth* This field is required.
Your Birth Date
Month
Day
Year
5
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Phone Number* This field is required.Please list your BEST number for us to contact you
Area Code
Phone Number
7
Email* This field is required.
example@example.com
8
Occupation* This field is required.
Occupation
Employer
9
Marital Status* This field is required.
S
D
W
M
10
Spouse* This field is required.
Spouse's Name
Spouse's Occupation
11
Whom can we thank for referring you to our office?* This field is required.
12
Emergency Contact Information* This field is required.
Name
Relationship
Phone Number
13
Do you have children?* This field is required.
YESNO
14
Number of Children and Ages * This field is required.Please list the names and ages of your children.
Huge
Large
Normal
Small
Ok
Ok
15
Have any of your children had previous chiropractic care?* This field is required.
YESNO
16
Have you ever received chiropractic care? * This field is required.
YESNO
17
Previous Chiropractic Care * This field is required.
Name of Chiropractor you received care with
Reason for care
How long did you receive care?
Date of last visit
How did you respond with care?
18
Have you ever consulted or do you regularly consult with any of the following providers for care? Check all that apply:* This field is required.
Naturopath
Acupuncturist
Homeopath
Energy Healer
Psychotherapist
Massage Therapist
Other
None
19
Primary Care Provider * This field is required.
Name of Primary Care Provider
Date of Last Visit
20
Do you have a present Complaint or Concern?* This field is required.You deserve to be healthy. When you were conceived, you were given the blue-prints, intelligence, and systems to live an active, healthy, long life. Unfortunately, the natural expression of your health can be interfered with. Through your examination and through your involvement in chiropractic care, we will work to remove these interferences and keep them out of your life, so that you can heal quickly and live the quality lifestyle you deserve.
YESNO
21
What is the reason for your visit today?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
22
When did this condition begin?* This field is required.
23
Is the condition:* This field is required.Choose one of the following
Getting worse
Improving
Constant
Intermittent
Unsure
24
How did the condition start?* This field is required.
Suddenly
Gradually
Post-Injury
Auto Accident
25
What makes the condition better?* This field is required.
26
What makes the condition worse?* This field is required.
27
Is condition worse during certain times of the day?* This field is required.
No
Morning
Afternoon
Evening
Night
28
Have you ever had a similar condition before?* This field is required.
YESNO
29
Is this condition interfering with:* This field is required.
Work
Sleep
Daily Routine
Hobbies
Exercise
None
30
Please explain how this condition interferes with daily life:* This field is required.
31
Previous Care* This field is required.
Who have you seen for this condition?
How did you respond?
32
Please check if you currently have or have had any of the following conditions:* This field is required.
Asthma
Allergies
Anxiety or Nervousness
Autoimmune Disease
Blurred Vision
Cancer
Chest Pains
Cold Feet or Hands
Cold Sweats
Consitpation/Diarrhea
Depression
Diabetes
Digestive Problems
Dizziness
Ears Ring
Fainting
Fatigue or Low Energy
Gout
Heart Burn
Heart Problems
Hernia
High Blood Pressure
Irregular Menstrual Cycle
Irritability
Kidney Stones
Loss of Balance
Loss of Memory
Loss of Smell or Taste
Numbness Fingers/Toes
PMS
Poor Posture
Prostate Trouble
Sensitive to Light
Shortness of Breath
Sleeping Problems
Stomach Ulcer
Stroke
Tendonitis
Thyroid Condition
Urinary Frequency
None
33
Are you currently taking any prescription drugs?* This field is required.
YESNO
34
Please list prescription drugs * This field is required.
Please list any side effects you experienced from the drugs
35
Have you had surgery?* This field is required.
YESNO
36
Surgery * This field is required.
Please explain what type of surgery AND when
Side effects you experienced from the surgery
37
What was YOUR birth process like?* This field is required.
Vaginal
Medications
Forceps
Caesarian
Breach
Episiotomy
Epidural
Induced
Home or Water Birth
Vacuum Extraction
38
Did you ever once...* This field is required.
Learn to care for your spine
Fall out of bed
Breastfeed
Have surgery
Take drugs
Fall while learning to walk
Get spanked
Fall down stairs
Pulled by your arm
39
Do you smoke?* This field is required.
YESNO
40
How often?* This field is required.
Daily
Weekends
Occasional
41
Do you drink alcohol?* This field is required.
YESNO
42
How often?* This field is required.
Daily
Weekends
Occasional
43
Do you exercise?* This field is required.
YESNO
44
How often?* This field is required.
1-2x/week
3-4x/week
5x or more/week
45
Please list the type of exercise(s)* This field is required.
46
Do you eat healthy?* This field is required.
YESNO
47
How often?* This field is required.
1-2x/week
3-4x/week
5x or more/week
48
Do you have:* This field is required.
Teeth problems
Eye problems
Hearing problems
None
49
How many hours do you sleep a night?* This field is required.
Less than 5 hours
5-7 hours
7-9 hours
More than 9 hours
50
Rate the stress regarding your life in general:* This field is required.
Very High
High
Moderate
Low
Very Low
51
Rate the stress regarding finances:* This field is required.
Very High
High
Moderate
Low
Very Low
52
Rate your stress regarding relationships:* This field is required.
Very High
High
Moderate
Low
Very Low
53
How would you rate your physical health?* This field is required.
Excellent
Good
Fair
Poor
54
How would you rate your mental/emotional health?* This field is required.
Excellent
Good
Fair
Poor
55
How would you rate your overall quality of life?* This field is required.
Excellent
Good
Fair
Poor
56
Female History* This field is required.
Please list your number of pregnancies
Please list number of vaginal deliveries
Please list number of Casarean surgery
Please list number of miscarriages
57
Deliveries were at:* This field is required.
Home
Birth Center
Hospital
Other
N/A
58
Have you ever taken birth control medication?* This field is required.
YESNO
59
Have you ever had infertility issues?* This field is required.
YESNO
60
Date of last menstrual cycle:* This field is required.
61
Have you experienced infertility issues with your spouse?* This field is required.
YESNO
62
Erectile dysfunction?* This field is required.
YESNO
63
Difficulty/pain during urination?* This field is required.
YESNO
64
Date of last prostate exam?* This field is required.
65
What are your personal and family's health goals?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
66
How do you expect to achieve these goals?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
67
Is there anything else you'd like to discuss with the Doctor today that you have not listed previously?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
68
Upon the completion of your first visit, you will receive a Chiropractic Report to discuss the different types Active Life Plans that are available to you. Active Life Plans are designed to get you feeling better quickly and to help you and your family be as healthy as possible. Please review the Active Life Plan Explanations prior to your Chiropractic Report so you can choose the level of participation that supports you in reaching all of your health goals.* This field is required.As a result of my chiropractic care, I would like to (check all that apply):
Feel better quickly
Live a healthier lifestyle
Correct the cause of a problem as well as relief
Healthier spine and nervous system
Prevent future problems
Optimal health on all levels
69
Signature: Terms of Acceptance * This field is required.When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be able to attain it. This will prevent any confusion or disappointment. Adjustment: An adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine. Health: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity. Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body’s innate ability to express its maximum health potential. We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal evaluation, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. Our only practice objective is to eliminate a major interference to the expression of the body’s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations. All questions regarding the doctor’s objectives pertaining to my care in this office have been answered to my complete satisfaction. I therefore accept chiropractic care on this basis.
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70
Signature: Consent to Care* This field is required.I do hereby authorize the doctor of Nexus Family Chiropractic to administer chiropractic care that is necessary for my particular case. This may include consultation, examination, adjustments or any other procedure which is advisable and necessary for my health care. I further understand that a fee for services rendered will be charged and that I am responsible for this fee whether results are obtained or not. I also clearly understand that if I do not follow the doctors specific recommendations at Nexus Family Chiropractic that I will not receive the full benefit from the services, and that if I terminate my care prematurely that all fees incurred will be due and payable at that time. I understand that payment for care is out-of-pocket and paid before or directly after services are rendered. If I wish to obtain reimbursement from my health insurance company, Nexus Family Chiropractic will supply the proper documentation necessary to receive reimbursement for services. Nexus Family Chiropractic is not liable for any lack of reimbursement from my health insurance company. I have read, understand, and hereby request chiropractic care based on the terms of acceptance and the consent to care.
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71
Signature: Healthcare Authorization* This field is required.The following authorizes Nexus Family Chiropractic to use and/or disclose protected health care information in accordance with the following specific authorizations: I give permission to Nexus Family Chiropractic to use my name, address, phone numbers, and clinical records to contact me with birthday cards, holiday related cards, health related-emails and information about treatment alternatives or other health related information, as well as my advertisements, newsletters, or patient of the week/month postings. I give permission to Nexus Family Chiropractic to treat me in an open room where other patients are also being treated. I am aware that other persons in the office may overhear some of my protective health care information during my treatment. Should I need to speak with a doctor in private, the doctor will provide a private room for these conversations. By signing the following you are giving Nexus Family Chiropractic permission to use and disclose your protected health information in accordance with the directives listed above. ACKNOWLEDGEMENT OF RECEIPT & NOTICE OF PRIVACY PRACTICES I understand and have been provided with a notice of information practices that provides me a more complete description of information uses and disclosures, I understand that I have the following rights and privileges: * The right to review the notice prior to signing this consent * The right to object to the use of my health care information for directory purpose * The right to request restrictions as to how my health care information may be used or disclosed in this office to carry out treatment, payment, or health care operations.
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