CONFIDENTIAL PATIENT INFORMATION First Name: Last Name: Today’s Date:

Address: City: State: Zip:

Cell Phone: Other Phone: Email:

Birthdate: Sex: SS#:

Marital Status: # of Children: Occupation:

Emergency Contact: Emergency Phone: Emergency Relationship:

How did you hear about us?

Who is your Primary Care Physician?

Are you also receiving care from other health professionals? If yes, Name of Professional and specialty:

What is your Primary Complaint that prompted you to seek care?

When did this begin?

How did this begin?

What relieves the problem?

What aggravates the problem?

Has this problem? Gotten Worse Stayed Constant Come and gone

Other treatment that you have sought for this problem?

Medication Surgery Physical Therapy Acupuncture Chiropractic Massage Ice Heat

What is your Secondary Complaint?

When did this begin?

How did this begin?

What relieves the problem?

What aggravates the problem?

Has this problem? Gotten Worse Stayed Constant Come and gone

Other treatment that you have sought for this problem?

Medication Surgery Physical Therapy Acupuncture Chiropractic Massage Ice Heat

Please indicate below where you are

experiencing pain or discomfort

Adult Patient Questionnaire

Review of health history

Check any condition you HAVE (at present) and any you have HAD (in the past)

Have Had GENERAL Dizziness Trouble swallowing

Fainting / Unexpected Fall Slurred or Slow Speech

Visual Disturbance Nausea

Numbness / Tingling Poor Co-ordination

Have Had CARDIOVASCULAR Blood Clot / Disorder Heart Attack Stroke Chest pain Low / High blood pressure Excessive Bruising

Have Had GENITOURINARY PMS symptoms Kidney infection / stones Prostate issues Difficulty / uncontrollable urination Infertility Bedwetting

Have Had NEUROLOGICAL Anxiety Depression Headache Ringing in ears Weakness

Have Had DIGESTIVE Heartburn / Ulcers Vomiting Food sensitivities Constipation Diarrhea

Have Had RESPIRATORY Hay fever Pneumonia Shortness of breath Asthma Apnea Emphysema

Arthritis Cancer Diabetes Genetic Disorders Osteoporosis Fever / Sweats Rapid weight loss / gain Pain with cough / sneeze / toilet

Yes No WOMEN Are you taking birth control? Are you pregnant? Are you nursing?

Is there anything else we should know about your health?

Yes No Note any significant family medical history:

TOXIN: Chemical and Environmental Exposure

List any drugs / medication / vitamins / herbs / that you are taking: Please rate your CONSUMPTION for each

Cigarettes ---------O---------O---------O--------O--------O Water---------------O---------O---------O--------O--------O Processed Foods-O---------O---------O--------O--------O Alcohol-------------O---------O---------O--------O--------O

TRAUMAS: Physical Injury History

Have you ever had any significant falls, surgeries, car accidents or

other injuries?

Notable childhood injuries?

None Moderate High

THOUGHTS: Emotional Stresses and Challenges

Please rate your STRESS for each:

Home ---------O---------O---------O--------O--------O Work ---------O---------O---------O--------O--------O Life ---------O---------O---------O--------O--------O

Notes:

None Moderate High

ACKNOWLEDGEMENT & CONSENT

Name: _________________________________________________ Date:____________________

Canning Chiropractic | www.canningchiro.com 78 Scenic Hwy, Lawrenceville, GA, 30046 | (770) 513 - 1591

TOXIN: Chemical and Environmental Exposure

Have Had