Active Life Chiropractic
Name Date of Birth Age:
Gender MaleFemale
Address Email
Marital Status SingleMarried
Occupation Employer Name of Emergency Contact Number of Emergency Contact Relationship City State Zip Mobile
Please identify the condition(s) that brought you to this office : First Second Third
On a scale of 1 to 10 with 10 being the worst pain and zero being no pain, rate your above complaints by circling the number: Primary complaint: 012345678910 Second complaint: 012345678910 Third complaint: 012345678910
When did the problem(s) begin? When is the problem at its worst? AMmid-dayPMlate PMat night
How long does it last?
It is constant ORI experience it on and off during the day ORIt comes and goes throughout the week
How did the problem happen?
Condition(s) ever been treated by anyone in the past? YesNo if Yes, who by whom (MD, DC, etc)? How long were you under care?: What were the results? Name of Previous Chiropractor When was your last adjustment?
*PLEASE Describe the areas on the Diagram with the following letters to describe your symptoms: R = Radiating B = Burning D = Dull A = Aching N = Numbness S = Sharp/ Stabbing T= Tingling
What relieves your symptoms? What makes them feel worse Identify any other injury(s) or conditions of your spine, minor or major, that the doctor should know about (surgeries, fractures, diseases, etc)
Have you suffered with this or a similar problem in the past? YesNo If yes how many times?
When was the last episode? How did the injury happen?
Other forms of treatment tried YesNo If yes, please state what type of treatment and who provided it How long ago?
What were the results?? FavorableUnfavorable please explain
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