Adobe FormsCentral

It has been a while since your last visit and we want to make sure that we are up to date on your health and wellness needs. Please take a moment to complete this short questionnaire so that we can update our files.
Last name*
First name*
E-mail*
CONTACT INFORMATION
My contact information has not changed since my last visit:

TrueFalse (if false, please provide updated information below)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
WHAT IS THE REASON FOR YOUR RETURN AT THE CLINIC?
Where is/are the problem(s)? Please use the lines below to explain.
*
How long has this been going on?
When did this incident occur?
Is this related to:

Workplace injurySportsPersonal injuryAuto accident
Do you have:

PainNumbnessTinglingAches
Is your pain:

SharpDullThrobbingConstantIntermittent
Are your symptoms affected by:

SittingStandingWalkingBendingLying downWeather
Do your symptoms interfere with:

WorkSleepDaily ActivitiesHobbies and leisure activities

On a scale of 1-10 (1 = least, 10 = most), please rate the severity of your symptoms

	1	2	3	4	5	6	7	8	9	10

1 is Least, 10 is Most

Do you get headaches?

YesNo
How often?
Are you receiving care from any other health professionals?

YesNo
If yes, please name them and their speciality:
GENERAL HEALTH HISTORY
Past injuries can affect present health.
Please check all that apply:

Falls/accidentsSports injuriesHead injuries/concussionsBroken bonesKnocked unconsciousCar accidentsSurgeryJoint replacementStrokePacemaker
If you answered Yes to any of the above, please describe:
Please list any medications you are taking and the reason for the medication:
Please list any vitamins or supplements that you are taking:
Do you wear orthotics or heal lifts?

YesNo
Have you ever had X-rays taken of your:

NeckBackNeither
If yes, please tell us where and when these X-rays were taken:
Do you have any other health concerns we should know about?

YesNo
If Yes, please describe:

Thank you for filling out our Chiropractic Welcome Back Health Questionnaire. We look forward to helping you with your health concerns and overall well-being!