Intake Form

Application for care at We Care Chiropractic

Today's Date
Name

PATIENT DEMOGRAPHICS

How did you find out about our office
Birth Date
Age
Gender
Address
City
State
Zip
Email Address
Mobile Phone (or contact)
Work Phone
Driver's License #
Social Security #
How many children?
Marital Status
Do you have insurance?
Employer
Occupation
Name & Number of Emergency Contact
Relationship

HISTORY OF COMPLAINT

What problem can We Care Chiropractic best help you with?
When did the problem(s) first begin (even if it has been on and off for a while)?
Condition(s) ever been treated by anyone in the past?
What type of practitioner?
What were the results?
How many chiropractic visits have you had in a lifetime?
Do you feel the problem was actually getting fixed or was the care more just relief?
What surgeries have you had?
What activities do you LOVE doing, what is fun for you?
What activities do you LOVE doing, what is fun for you?
What do you want to change about your life?

STRESS

State any physical stresses that have impacted your body and the year they happened.
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Car Accidents
Broken Bones
Stitches
Sports Injuries
Work Injuries
Others
How would you rate your mental/emotional stress like family, relationships, children, spouse, work, co-workers etc...
on a scale 1-10 (10 means worrying often?
What are the sources of this stress?
Please rate and answer the following questions in regards to chemical stress your body is dealing with:
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How much unhealthy foods do you eat 0-10 (10= sugars, fast foods, breads, pastas, sweets)?
How often do you use tobacco products 0-10 (10=daily)?
How often do you use alcohol products 0-10 (10=daily)?
Please list any medication(s) you currently take (prescription and non prescription)
What condition is it treating?
Side Effects

HEALTHY LIFESTYLE HABITS

How much quiet time, relaxing, naps do you typically have in a week?
How often do you usually get checked by your chiropractor?
How much IUs of vitamin D3 do you take and how often?
How much healthy Omega Fats (fish oil, flax oil, coconut oil) do you take?
Do you take a multi vitamin and mineral?
Do you take probiotics and how powerful of dose?
What does your spiritual life look like?
How many days per week do you average working out in the last 90 days?
How much healthy foods do you eat 0-10 (10=lots of good fats, vegetables, fruits, grass fed meat, game etc)?
Please list all other supplements (whey protein) and/or vitamins that you take
Please mark P for in the Past, C for Currently have, and N for Never

Headache
Neck Pain
Jaw Pain, TMJ
Shoulder Pain
Upper Back Pain
Mid Back Pain
Low Back Pain
Hip Pain
Back Curvature
Scoliosis
Numb/Tingling arms, hands, fingers
Numb/Tingling legs, feet, toes
Trouble Sleeping
Frequent Colds/Flu
Convulsions/Epilepsy
Tremors
Chest Pain
Pain w/Cough/Sneeze
Foot or Knee Problems
Sinus/Drainage Problem
Swollen/Painful Joints
Nauseous
Dizziness
Loss of Balance
Fainting
Double Vision
Hearing Loss
Depression
Irritable
Mood Changes
ADD/ADHD
Allergies
Prostate Problems
Impotence/Sexual Dysfun.
Colon Trouble
Constipation
Diarrhea
Menopausal Problems
Menstrual Problem/PMS
Digestive Problems
Bed Wetting
Learning Disability
Eating Disorder
High Stress
Ulcers
Heartburn
Heart Problem
High Blood Pressure
Low Blood Pressure
Asthma
Difficulty Breathing
Lung Problems
Kidney Trouble
Gall Bladder Trouble
Liver Trouble
Hepatitis (A,B,C)
admin none 7:45am - 10:00am 3:00pm - 6:00pm Closed 7:45am - 10:00am 3:00pm - 6:00pm 3:00pm - 6:00pm 7:45am - 10:00am By Appointment Closed chiropractor # # #