Chiropractic Health Profile
HEALTH CONCERNS
CONSENT FOR A MINOR/CHILD
Patient Name
First Name
Last Name
Today’s Date
Date of Birth
Age
Gender
Address
Street Address
Street Address 2
City
State
Zip Code
Country
Home Phone (With area code)
Cell Phone (With area code)
Work Phone (With area code)
Patient E-Mail
Children
Name of Child 1
Age of 1st Child
Gender 1st Child
Name of Child 2
Age 2nd Child
Gender 2nd Child
Personal Details
Employer
Occupation
Marital Status
Spouse’s Name
Spouse’s Date of Birth
Contact in case of Emergency
Emergency Contact Phone
Whom may we thank for referring you to this office?
Name of Primary Insurance
Name of Insured
Insured Date of Birth
Insured SSN#
Name of Secondary Insurance
Name of Insured
Insured Date of Birth
Insured SSN#
HEALTH CONCERNS
Primary Health Concern
Severity (10=Unbearable)
Episode Start Date
Result of Injury?
Are Symptoms?
Additional Health Concern 1
Severity 1 (10=Unbearable)
Episode Start Date 1
Result of Injury? 1
Are Symptoms 1
Additional Health Concern 2
Severity 2 (10=Unbearable)
Episode Start Date 2
Result of Injury 2 ?
Are Symptoms 2
Additional Health Concern 3
Severity 3 (10=Unbearable)
Episode Start Date 3
Result of Injury 3 ?
Are Symptoms 3
Additional Health Concern 4
Severity 4 (10=Unbearable)
Episode Start Date 4
Result of Injury 4 ?
Are Symptoms 4
Condition(s) ever been treated by anyone in the past?
If Yes which profession?
If yes, please list when and by whom?
Check all that apply
Check any condition you have now / have had:
List all surgical operations and years
List all over the counter and prescription medications you are on:
When was your last auto accident
Have you had previous chiropractic care?
If you have, Please list Doctors Name and Date
Have you ever been knocked unconscious?
Fractured a bone?
If yes please describe
Other trauma
LIST YOUR CURRENT HEALTH GOALS BELOW
Health Goal
Date To Accomplish
Significance of Goal
FAMILY HEALTH HISTORY
This is to assist the doctor by providing past health history information for his review. Please check all that apply
Arm Pain
Arthritis
Asthma
ADD/ADHD
Allergies
Back Trouble
Bed Wetting
Cancer
Carpal Tunnel
Diabetes
Digestive Problems
Disc Problems
Ear infections
Fibromyalgia
Headaches
Heartburn
High Blood Pressure
Hip Pain
Leg Pain
Menstrual Disorder
Migraines
Neck Pain
Scoliosis
Shoulder Pain
Sinus Trouble
TMJ
CONSENT FOR A MINOR/CHILD
IF THIS HEALTH PROFILE IS FOR A MINOR/CHILD, PLEASE FILL OUT AND SIGN BELOW WRITTEN CONSENT FOR A CHILD. I AUTHORIZE THE CHIROPRACTIC STAFF TO PERFORM DIAGNOSTIC PROCEDURES, RADIO-GRAPHIC EVALUATIONS, RENDER CHIROPRACTIC CARE AND PERFORM CHIROPRACTIC ADJUSTMENTS TO MY MINOR/CHILD. AS OF THIS DATE, I HAVE THE LEGAL RIGHT TO SELECT AND AUTHORIZE HEALTH CARE SERVICES FOR MY MINOR/CHILD. IF MY AUTHORITY TO SELECT AND AUTHORIZE CARE IS REVOKED OR ALTERED, I WILL IMMEDIATELY NOTIFY THIS OFFICE.
Name of practice member who is a minor/child
Date
Guardian’s Relationship to Minor or Child
Patient or Authorized Person’s Electronic Signature
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