New patients please print and fill this form out and bring with you to your first appointment.

Carthage Chiropractic Health Questionnaire

Name

Address

City State Zip code

Home Phone Cell Phone

Date of Birth / / Male Female

Age

SS#

Occupation Marital Status: M W D S Spouse Name

No# of Children Name of Children

Insured’s Name (if other than self) _____________________________________________ Birth date ___________________________________________

Many patients are referred to our office by a family member or friend. What or who made you decide to visit our office?

Science tells us your spine like your teeth need to be cared for regularly. When was your last complete spinal examination including x-rays?

Do you know if you have a spinal curvature, spinal arthritis, or inherited spinal problems?

Over time spinal misalignments will cause arthritis and degeneration which results in grinding or cracking to be heard when you move your neck or back as well as, loss of Nerve Health.

Do you hear these sounds when you move your head or neck?

Yes No

If your spine is out of alignment for a long time it can make you feel like you need to twist, stretch, or crack your neck or back.

Do you often feel the need to crack or pop your neck or lower back?

Yes No

Do you have any of the following conditions?

Thyroid

Allergies:

Poor posture leads to poor health and early death.

How would you rate your posture?

Poor 1 2 3 4 5 6 7 8 9 10 Excellent

Stress causes your spine to misalign and accelerates spinal damage. Rate your stress level over the last 3 months.

None 1 2 3 4 5 6 7 8 9 10

Intense Please circle or list any health symptoms or health complaints you are experiencing.

Neck pain L/R Leg pain L/R Heart Disease

Mid-back pain Asthma Cancer

Low-back pain Headaches/Migraines Constipation

Arm pain/Numbness L/R Diabetes I/II Menstrual pain

Prescription medications cause various side effects hide the severity of health problems and hinder the body's ability to heal.

What medications are you currently taking? (use back if necessary)

Please list any surgeries you have had.

Do You Smoke? Yes No

Spinal health is vitally important to ensure you and your baby are healthy. Is there a chance you are pregnant? Yes No

Daily trauma, auto accident(s), and work injuries can cause misalignment of vertebrae and serious spinal problems.

When was your most recent injury at home?

Car accident?

Slip or fall?

Improper sleeping positions can cause spinal misalignment and spinal damage.

What sleeping position do you sleep in: Back Stomach

R Side L Side

Exercise level: Never 1 2 3 4 5 6 7 8 9 10 Often

Are you ? Right Handed Left Handed

Please list vitamins/supplements you take:

If the doctor identifies your spine to be misaligned, are you committed to follow the recommendations to correct your problem completely?

Yes No

The above information is true and accurate to the best of my knowledge.

Patient Signature (Parent/Guardian):

Date:

Carthage Chiropractic Care…Wellness Begins Here