Adult History Form. Personal Information. Name: Birthdate: Age: Social Security number: Street Address: Cell:
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1 Date: Adult History Form Please complete this detailed history form and return it to the front desk. If you have any questions or need assistance with anything, please let us know. Personal Information 15 E Central Ave, Ste 3 Spokane, WA info@betterlifespokane.com Name: Birthdate: Age: Social Security number: Street Address: City State Zip Home phone: Cell: OK to leave detailed message? (circle) No Yes on Home Yes on Cell Yes on both Emergency Contact: Phone: Relationship to you: Ok to leave detailed message? Yes No Job Status: Employed Unemployed Student Retired Other Workplace: Occupation: Address: Phone: Marital Status: Single Married Engaged Cohabitating Divorced Other: Have you seen a chiropractor before? No Yes Date of Last Visit: Name of Previous Chiropractor: Specialty: Were you pleased with your care? No Yes If no, please explain: How did you find our office? (name & details) Friend Online Business Card Another patient Midwife Doula OB Other Provider N/A Is this visit related to an auto accident? (circle) No Yes Work Injury? (circle) No Yes Women Only Are you currently nursing? (circle) No Yes If yes, any difficulties? Do you have a history of painful periods? No Yes Are you currently on birth control? No Yes Have you been diagnosed with? PCOS Endometriosis Other Difficulty conceiving Recurrent Miscarriages Do these apply to you? (circle) Painful Periods Irregular Cycles Breast Implants 1
2 Do you receive care from other health professionals? No Yes If yes, please list with specialty: Why are you coming to see us? Date of onset: Onset was (circle one): Sudden Gradual Associated to an event Is the condition: (circle) Getting Worse Getting Better Constant Unsure Duration of Condition: (indicate & circle) Minutes Hours Days Months Years Pattern of Condition: (circle one) Constant Intermittent/Episodes Occasional Cyclical List any other care you have undergone for this condition including medication/supplements/diet: Initiating Factors: Aggravating/Contributing Factors: Relieving Factors: How does the problem affect your body function and daily activities? Prior occurrence or episodes? Related health concerns: What other health concerns do you have? Your Own Birth Place of birth (circle): Home Hospital Birth Center Other: Birth was (circle): Vaginal Vag w/ interventions VBAC Scheduled Cesarean Emerg. Cesarean HBAC Were interventions used? (circle & indicate): No Yes If yes, what? (circle) Epidural Episiotomy Pain Medication Forceps Vacuum Extraction Induced Labor Other: Any evidence of trauma (circle)? No Yes (circle to specify) - Bruises Odd shaped head Stuck in birth canal Meconium inhalation Fast and/or excessively long birth Antibiotics during labor Abnormal breathing Cord around neck Other: Were you alert & responsive within 12 hours of delivery? No Yes If no, explain: Were you under NICU care? No Yes Explain: The following information is very important because many of the problems that chiropractors work with are caused by various stressors. 2
3 Structural Stressors Detail major injuries, accidents, falls, stitches, and/or fractures (include year): Any hospitalizations/surgeries? No Yes If yes, what? (include year): Do/did you play sports? No Yes Which sport? Hrs per week? Age started playing? Any injuries? Exercise regularly? No Yes Which type? Hrs per week? Chemical Stressors Smoke - No Yes If yes: Tobacco Marijuana Take drugs - No Yes If yes, what? Drink alcohol - No Yes If yes: Beer Wine Liquor Other If yes, how often? Receive vaccines - No Yes If yes, which one(s)? Any reactions? No Yes If yes, what? Any food reactions/intolerances? Any regular antibiotic use? No Yes If yes, how much & why? Any pets at home? No Yes Any smokers at home? No Yes If yes, how much/often? Please list any vitamins/herbs/homeopathic/medicine/other you are currently taking: Any allergies? No Yes If yes, what?: Are you frequently sick? No Yes If yes, types and frequency: Psychological Stressors Any difficulties sleeping (night terrors, sleepwalking, bedwetting etc.)? No Yes If yes, specify what & when: Average hours for you per week of: TV hrs mins Computer hrs mins Tablet hrs mins Phone hrs mins Driving hrs mins Sitting hrs mins Did you have behavioral problems as a child? No Yes If yes, what? Did you have difficulty sleeping as a child? No Yes If yes, why? 3
4 Family History Circle those involving immediate family and add identification M = Mother, F = Father, S = Siblings, G = Grandparents Cancer (Type(s)): Seizures Osteoarthritis Neck Problems Depression Diabetes Back Problems Heart Disease Liver Disease High Blood Pressure Rheumatoid Arthritis Lung Problems Scoliosis High Cholesterol Osteoporosis Other: What Do You Know About Chiropractic? Do you know what a subluxation is? No Yes Do any of your friends or family members see a chiropractor? No Yes If yes, why? Health Maintenance Wellness Optimization Health Problems Injury Other: What would you like to gain from chiropractic care? Rate the importance of finding the cause of your problem: (not) (very) Rate how important your quality of life is to you: (not) (very) What excuse has stopped you from achieving Optimal Health? Money Time Lack of provider Distance Other: Are there any other health concerns or anything else you would like us to know about you? 4
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Personal Inventory We realize that you are just beginning to express interest in learning about our way of life. We hope that the information provided in this website will answer some of your questions,
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DEMOGRAPHIC INFORMATION, New Patient Patient Information PCP: Patient Name: Mailing Address: Primary Phone: ok to leave brief msg? ok to leave detailed msg? Second Phone: ok to leave brief msg? ok to leave