Jauch Chiropractic
Patient Information
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Last Name
Telephone
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Zip
Birth date:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
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31
Year
Height
'
"
Weight
lbs.
Status:
Married
Single
Widowed
Divorced
Sex:
M
F
# Children
Occupation
Employer
Work Phone
Ext.
Health Information
Primary Care Physician
Briefly Describe Your Current Problem
How Your Problem Began
Date Problem Started
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
2
3
4
5
6
7
8
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13
14
15
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17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Treatments for This Condition?
What Kind of Tests and When?
How Bad Is Your Pain?
0
1
2
3
4
5
6
7
8
9
10
No Pain
Unbearable Pain
How often are your symptoms present?
Constantly
Frequently
Occasionally
Intermittently
Describe your
current
pain/symptoms:
Sharp/Stabbing
Throbbing
Aches
Dull
Soreness
Weakness
Numbness
Shooting
Gripping
Burning
Tingling
Other
Since it began, is your problem:
Improving
Getting Worse
No Change
What makes the problem better?
Nothing
Lying Down
Walking
Standing
Sitting
Movement
Exercise
Inactivity/Rest
Other
What makes the problem worse?
Nothing
Lying Down
Walking
Standing
Sitting
Movement
Exercise
Inactivity/Rest
Other
Can you perform your daily home activities?
Yes
Yes, only with help
Not at all
Do you exercise?
Yes, almost daily
Yes, occasionally
Not at all
Describe your job requirements:
Mainly Sitting
Light Labor
Heavy Labor
Describe your stress level:
None to Mild
Moderate
High
For each of the conditions listed below, place a check in the
Past
column if you have had the condition in the past. If you presently have a condition listed below, place a check in the
Present
column.
Past
Present
Headaches
Neck Pain
Upper Back Pain
Mid Back Pain
Low Back Pain
Shoulder Pain
Elbow/Upper Arm Pain
Wrist Pain
Hand Pain
Hip/Upper Leg Pain
Knee/Lower Leg Pain
Ankle/Foot Pain
Jaw Pain
Joint Swelling/Stiffness
Arthritis
Rheumatoid Arthritis
General Fatigue
Muscular Incoordination
Visual Disturbances
Dizziness
Past
Present
High Blood Pressure
Heart Attack
Chest Pains
Stroke
Angina
Kidney Stones
Kidney Disorders
Bladder Infection
Painful Urination
Loss of Bladder Control
Prostate Problems
Abnormal Weight Gain/Loss
Loss of Appetite
Abdominal Pain
Ulcer
Hepatitis
Liver/Gall Bladder Disorder
Cancer
Tumor
Asthma
Chronic Sinusits
Past
Present
Diabetes
Excessive Thirst
Frequent Urination
Smoking/Use Tobacco Products
Drug/Alcohol Dependence
Allergies
Depression
Systemic Lupus
Epilepsy
Dermatitis/Eczema/Rash
HIV/AIDS
Females Only
Birth Control Pills
Hormonal Replacement
Pregnancy
Other Health Problems/Issues
Indicate if an immediate family member has had any of the following:
Rheumatoid Arthritis
Heart Problems
Diabetes
Cancer
Lupus
Other
List all prescription drugs, over-the-counter drugs, and nutritional supplements you are taking:
List all the surgical procedures you have had and times you have been hospitalized:
Please check any boxes that represent where you have pain or other symptoms.