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Personal History Form

The following is a confidential questionnaire which will help us determine the best possible course of treatment for you. Please take your time and complete the information accurately. Thank you!

Date

Personal Information

First Name*

Last Name*

Birthday*

Address

City

State

Zip

Phone

E-mail address

Gender

Pronoun

Sex assigned at Birth

Employer

Occupation

Employment address

In case of emergency contact

Emergency Contact Work Phone

Referred by

Have you ever been treated by a chiropractor before?

Yes

No

How would you describe your chief complaint at this time?

Complaint Details

When did it start?

What makes the pain worse?

What makes the pain better?

How would you describe your pain?

1. Please indicate your usual level of pain during the past week:

0 (No Pain)

1

2

3

4

5

6

7

8

9

10 (Worst Possible Pain)

At what time of the day or week is your pain worse?

The pain is:

Intermittent

Constant

Have you had this problem in the past?

If so, how often?

Physical Activity

How many times a week do you engage in physical activity that is sufficiently prolonged and intense to cause sweating and raise your heart rate?

When you engage in the physical activity noted above, what is the average duration of activity?

Less than 10 minutes

10 - 20 mins

20 - 30 mins

30 - 60 mins

Over 60 mins

For Medical and Insurance Purposes Only

When you engage in the physical activity noted above, what do you feel the level of effort is?

At work, how many days per week do you engage in tasks that are intense enough to cause sweating and a rapid heart rate?

Please rate your level of fitness (0 = very poor, 5 = average, 10 = excellent)

Please rate your level of fitness (0 = very poor, 5 = average, 10 = excellent):

0 (Very Poor)

1

2

3

4

5 (Average)

6

7

8

9

10 (Excellent)

Is your pain the result of a motor vehicle accident?

Have you filed a legal suit?

Is your pain the result of a work related injury?

If so, have you filed a worker's compensation claim?

Please list Accidents, Injuries, Surgeries, and Hospitalizations you have had (include Date or Age):

Do you or other family members have a history of any of the following?

Rheumatoid Arthritis

Self

Family member

Asthma

Self

Family member

Cancer

Self

Family member

Diabetes

Self

Family member

Heart Disease

Self

Family member

Hypertension

Self

Family member

Hypoglycemia

Self

Family member

Kidney Disease

Self

Family member

Depression

Self

Family member

Mental Illness

Self

Family member

Do you drink coffee or black tea?

If so, how much per day?

If so, how much per day?

If so, how often?

What medications, vitamins, supplements, herbs do you take?

Name

Reason

Name

Reason

Name

Reason

Please list any allergies that you have:

Thank you for taking the time to fill out this form.

CONTACT US TODAY

We look forward to hearing from you

Location

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Office Hours

Our Regular Schedule

Arlington Chiropractic

Monday:

9:00 am-7:00 pm

Tuesday:

8:30 am-7:00 pm

Wednesday:

9:00 am-7:00 pm

Thursday:

9:00 am-7:00 pm

Friday:

8:00 am-5:00 pm

Saturday:

8:00 am-1:00 pm

Sunday:

Closed

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