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Personal Information

Full Name *

Date of birth

Age

Address

Street Address

City

State

Country

Postal Code

Phone *

What brings you in today? (Check all that applies)

Pain Level (1 lowest, 10 highest)

Referred by

Occupation

Employer

Marital Status

Spouse name

Children (number and Age)

Spouse date of birth

Email *

How long have you been experiencing this?

Additional Details

About Your Health

The human body is designed to be healthy. Throughout life, events occur which damage your health expression. This case history will uncover the layers of damage, especially to your nervous system, that resulted in poor health. You must remember that it was a process that got you to this point, and it will be a process to get you back to better health. Following your exam, your Chiropractor will outline a course of care to begin to correct these layers of damage and recover your innate health potential.

Have you ever visited a Chiropractor before? When was your last visit?

Loss of Wellness — Birth Process

Let’s begin at birth when you first damaged your nerve system, lost your wellness and began your journey to ill health

Was the delivery long?

Yes

"If yes, please explain"

Was the delivery difficult?

Yes

"If yes, please explain"

Was it a Forceps delivery or Caesarean?

Forceps

Caesarean

Neither

Not Sure

"If Neither or Not Sure Please Explain"

Home birth?

Yes

"If yes, please explain"

Hospital birth?

Yes

"If yes, please explain"

Mother given drugs during delivery?

Yes

"If yes, please explain"

Was labor induced?

Yes

"If yes, please explain"

Comments

Growth and Development

Were you taught how to care for your spine?

Yes

"If yes, please explain"

Did you fall out of bed?

Yes

"If yes, please explain"

Were you a head banger or rocker?

Yes

"If yes, please explain"

Were you breast fed?

Yes

"If yes, please explain"

Childhood sicknesses?

Yes

"If yes, please explain"

Childhood accidents?

Yes

"If yes, please explain"

Childhood surgery?

Yes

"If yes, please explain"

Childhood medications/drugs?

Yes

"If yes, please explain"

Did you fall while learning to walk?

Yes

"If yes, please explain"

Were you picked on by siblings?

Yes

"If yes, please explain"

Child abuse (spanking/pulled ear/hair)?

Yes

"If yes, please explain"

Were you yanked by your arm?

Yes

"If yes, please explain"

Chair pulled out when sat down?

Yes

"If yes, please explain"

Did you fall down stairs?

Yes

"If yes, please explain"

Childhood activities and sports?

Yes

"If yes, please explain"

Did you have other traumas? What? When?

Yes

"If yes, please explain"

Comments (Growth and Development)

Current Health Habits

Did/do you smoke/ drink any alcohol?

Yes

"If yes, please explain"

Diet (Do you eat healthy foods?)

Yes

"If yes, please explain"

Exercise regularly?

Yes

"If yes, please explain"

Have you been in any accidents? (Auto/ Home/ Work)

Yes

"If yes, please explain"

Did/do you have occupational stress?

Yes

"If yes, please explain"

Physical stress/ Mental stress?

Yes

"If yes, please explain"

Current activities, sports, and hobbies?

Yes

"If yes, please explain"

Sleeping posture

Side

Stomach

Back

Is it possible you are pregnant?

Yes

If Yes Mention Due Date.

Present Complaint

Pain or Problem started on

What activities aggravate your condition/pain?

What activities lessen your condition/pain?

Is condition worse during certain times of day?

Is this condition interfering with work?

Other Doctors seen for this condition:

Any home remedies?

Doctor’s Notes:

Other Indicators of Ill Health:

Are you currently under medical care?

Have you had surgery?

Yes

if yes when you had surgery?

What medications are you taking?

What side effects have you experienced from drugs/surgery?

Family history

What are your expectations of our office? Please rate each of the following on a scale of 1-5, 5 being very important

Resolving my current problem/ symptom orginal

Resolving my current condition

Preventing future problems

Restoring my family's overall health

About Your Care

Chiropractic provides three types of care. The first is Initial Intensive Care, which corrects the most recent layer of spinal and neurological damage (VSC). This care usually reduces or eliminates the symptoms. Then begins Reconstructive Care, which corrects the years of damage that occurred when there were few symptoms. And finally, Chiropractic offers a genuine approach to Wellness Care. All of these options will be explained at your report of findings. Then you will be able to begin a course of care that fits our health goals.

Sport Injuries

Our experienced chiropractors specialize in treating sports injuries, helping you recover faster and perform at your best. With our exclusive chiropractic care discount, you can get back in the game quicker and reach your peak performance.

Work Injuries

. Our chiropractic care is tailored to address work-related injuries and strains, providing relief and promoting a healthy workplace experience. Take advantage of our exclusive discount to prioritize your recovery and return to work feeling your best.

Physiotherapy

Our skilled physiotherapists will work closely with you to create a personalized treatment plan, focusing on rehabilitation and pain management. Experience the benefits of our physiotherapy services at a discounted rate, ensuring you receive the care you deserve for a healthier, more active life.

Exclusive Chiropractic Care Discount

Don't miss this opportunity to experience the expertise of our chiropractors while enjoying significant cost savings. Claim your exclusive discount today and take the first step toward a healthier, pain-free you.