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1 Name Patient # (PLEASE PRINT) Signature Date Height FT IN Weight Married? Y / N Employed? Y / N Previous Illnesses: Check all that apply AIDS, HIV, STD Epilepsy Pacemaker Alcoholism Eye/vision problems Parkinson Anemia Fainting Polio Aortic Aneurysm Fatigue Prostate problems Asthma Genetic spinal conditions Rheumatic fever Arthritis High blood pressure Scoliosis Bone Fractures High cholesterol Seizures Cancer Kidney stones Stroke/heart attack Chest Pain Liver trouble Significant weight gain Diabetes Low blood pressure Sinus trouble Digestive Problems Menstrual problems Thyroid disorders Dizziness Mental difficulties Other: Elbow Pain Multiple sclerosis Other: Emotional Difficulty Neurological problems Emphysema Obesity Surgeries: Check all that apply Appendectomy Gastric Bypass Mastectomy ACL Repair Hemilaminectomy Prostatectomy Caesarean Section Hernia Repair Shoulder Surgery Carpal Tunnel Decompression Hip Replacement Spinal Fusion Colostomy Kidney Transplant Spinal Stenosis Discectomy Knee Replacement Tonsillectomy Eye Surgery Laminectomy Vasectomy Gallbladder Lumbar Decompression Varicose Vein Removal Gastrectomy Lumbar Fusion Other Gynecological Surgery Lumpectomy Type: Current Medications: Check all that apply Anxiety Insulin Other: Allergy Muscle Relaxers Other: Birth control Pain Killers Supplements: Cardiovascular Seizures Vitamins: Allergies Seasonal Y / N Allergies to Medications Y / N Reaction 1
2 Family History: Check all that apply Arthritis Congenital Defects Headaches Prostate Problems Asthma Diabetes High Blood Pressure Scoliosis Back Problems Disc Problems Joint Problems Seizures Cancer Emphysema Migraine Headaches Thyroid Problems Chronic Pain Gallstones Osteoporosis Other: Do you drink alcohol? Never Occasionally Frequently Daily Do you drink caffeine? Never Occasionally Frequently Daily Do you use tobacco? Every Day Some Days Former Smoker Never Smoked Do you do substance Abuse? Never Occasionally Frequently Daily Do you exercise? Never Occasionally Frequently Daily Check reason(s) for consulting the office: Please mark your areas of pain below: 2
3 NECK Left Shoulder Right Shoulder Left Arm Right Arm Left Hand Right Hand Left Elbow Right Elbow Left Forearm Right Forearm Jaw Stabbing Stiffness Throbbing Tightness Tingling Traumatic injury Auto accident Sports injury Prolonged driving Excessive standing Excessive walking Arm Head Shoulder Pain 3
4 UPPER BACK MID BACK Left Shoulder Right Shoulder Left Arm Right Arm Left Hand Right Hand Left Elbow Right Elbow Left Forearm Right Forearm Stabbing Stiffness Throbbing Tightness Tingling Traumatic injury Auto accident Sports injury Prolonged driving Excessive standing Excessive walking Arm Head Shoulder 4
5 LOW BACK HIP Left Hip Right Hip Left Buttock Right Buttock Left Thigh Right Thigh Left Leg Right Leg Left Knee Right Knee Left Ankle Right Ankle Left Foot Right Foot Stabbing Stiffness Throbbing Tightness Tingling Traumatic injury Auto accident Sports injury Prolonged driving Excessive standing Excessive walking Leg RUSSELL CHIROPRACTIC HEALTH CENTER, P.C. DR. HUBERT W. RUSSELL, JR ALLEN ROAD, SOUTHGATE, MICHIGAN Telephone: (734) Fax (734)
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Today s Date: Name: What do you prefer to be called: Male / Female (please circle) Birth Date: Mailing Address: City: State: Zip: Home Phone: Cell Phone: Email: Referred By: Employer: How long employed:
Name Home phone Work phone. Address. Email address. Date of birth Gender (circle): M F Marital status No. of children. Name of partner Referred by
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