CONFIDENTIAL
HEALTH INFORMATION
Please allow our staff to photocopy your driver’s license and insurance details.
All information you supply is confidential. We comply with all federal privacy standards.
Please print clearly.
_______________________
Today’s Date
____________________________________________________
Whom may we thank for referring you?
Have you consulted a chiropractor before?
[ ] No [ ] Yes When?___________________________________________________________________________________________
If so, whom?
Gender
______________________________________________[ ] Male [ ] Female
__________________________________________
Your Last Name
Your Social Security Number
______________________________________________________________
Your First Name
Your Middle Name
__________________________________________
Your Date of Birth
______________________________________________________________
Your Street Address
[ ] Single
[ ] Married
[ ] Divorced [ ] Widowed
[ ]Minor Child
______________________________________________________________
City
State
Zip Code
______________________________________________________________
Your Email Address (For Appointment Reminders)
___________________________________
Home Phone
_________________________________________ _____________________________
Your Employer
Your Occupation
___________________________________
Work Phone
________________________________________________________________________
Emergency Contact and Phone Number
___________________________________
Patient Cell Phone (For reminder/text)
________________________________________ ___________________________________________________________________
Your Spouse’s Name
Your Primary Care Provider’s Name
----------------------------------------------------------------------------------------------------------------------------- --------------------------------------PRIMARY INSURANCE INFORMATION
_________________________________________ ___________________________________ _______________________________
Insurance Carrier
Policy Number
Group Number
_________________________________________
Insured’s Name
_________________________
Insured’s Date of Birth
Who carries this policy?
[ ] Self [ ] Spouse [ ] Parent
_________________________________________
Insured’s Employer
------------------------------------------------------------------------------------------------------------------------------------ -------------------------------SECONDARY INSURANCE INFORMATION
_________________________________________ ____________________________________ ______________________________
Insurance Carrier
Policy Number
Group Number
_________________________________________ __________________________
Name
Insured’s Date of Birth
________________________________________
Insured’s Employer
Who carries this policy?
[ ] Self [ ] Spouse [ ] Parent
[ ] MEDICARE SUPPLEMENT [ ] RETIREE PLAN
[ ] OTHER___________________________________
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1. The symptoms(s) that have prompted me to see care today include: _____________ ________________________
Patient Name
________________________________________________________________________
Consultation Notes:
________________________________________________________________________
2. And are the result of: [ ] An accident or injury
[ ] Work [ ] Auto [ ] Other________________________
[ ] A worsening long-term problem
[ ] Unknown cause
[ ] An interest in [ ] Wellness Care [ ] Other_____________
3. Onset (When did you first notice symptoms?) _______________________________
0
1
2
3
4
5
6
7
8
9
10
4. Intensity (How extreme are your current symptoms?) o—o—o—o—o—o—o—o—o—o—o
Check one
Absent
Uncomfortable
Agonizing
5. Duration and Timing (When did it start and how often do you feel it?)
[ ] Constant [ ] Comes and goes. How often?_______________________________
Quality of symptoms (What does if feel like?)
[ ] Numbness
[ ] Tingling
[ ] Stiffness
[ ] Dull
[ ] Aching
[ ] Cramps
[ ] Nagging
[ ] Sharp
[ ] Burning
[ ] Shooting
[ ] Throbbing
[ ] Stabbing
[ ] Other ________________________
7. Location (Where does it hurt?)
Mark the areas:
“O” for current conditions
“X” for conditions experienced in
the past.
8. Radiation (Does it affect other areas
of your body? To what areas does
the pain radiate, shoot or travel.)
_____________________________
_____________________________
9. Aggravating or relieving factors (What makes it better or worse, such as time of
day, movements, certain activities, etc.)
What tends to worsen the problem?________________________________________
What tends to lessen the problem? _________________________________________
10. What have you done to relieve the symptoms?
[ ] Prescription Medication
[ ] Surgery
[ ] Over the counter medication [ ] Acupuncture
[ ] Homeopathic medication
[ ] Chiropractic
[ ] Physical Therapy
[ ] Massage
[ ] Ice
[ ] Heat
[ ] Other _________________
11. What else should Dr. Kilguss know about your current condition?_____________ _______________
_____________________________________________________________________
Doctor’s Initials
Dr. Bea Kilguss
DeSoto Chiropractic Center
_____________________________________________________________________
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12. How does your current condition interfere with your:
____________________
Patient Name
Work or career: ______________________________________________________
Consultation Notes:
Recreational activities: ________________________________________________
Household responsibilities: _____________________________________________
Personal relationships: ________________________________________________
13. Review of Systems
Chiropractic care focuses on the integrity of your nervous system, which
controls and regulates your entire body. Please check any condition that you’ve
HAD or currently HAVE and initial to the right.
A. Musculoskeletal
Had Have
Had Have
Had Have
Had Have
[ ] [ ]Osteoporosis
[ ] [ ]Arthritis
[ ] [ ] Scoliosis
[ ] [ ] Elbow/Wrist pain [ ] NONE
[ ] [ ] Back problems [ ] [ ]Hip disorder [ ] [ ] Knee injury [ ] [ ] Foot/Ankle pain Initial___
[ ] [ ] Shoulder problem[ ] [ ]Neck pain [ ] [ ] TMJ issues [ ] [ ] Poor posture
B. Neurological
Had Have
[ ] [ ] Anxiety
[ ] [ ] Numbness
Had Have
Had Have
Had Have
[ ] [ ] Depression [ ] [ ] Headache [ ] [ ]Dizziness
[ ] [ ] Pins and Needles Feeling ______________________
[ ] NONE
Initial___
C. Cardiovascular
Had Have
Had Have
Had Have
[ ] [ ]High BP
[ ] [ ] Low BP
[ ] [ ] Angina
[ ] [ ]Poor circulation [ ] [ ] Excessive Bruising
Had Have
[ ] [ ] High Cholesterol [ ] NONE
Initial___
D. Respiratory
Had Have
[ ] [ ] Asthma
[ ] [ ] Pneumonia
Had Have
Had Have
Had Have
[ ] [ ] Apnea
[ ] [ ]Hay Fever [ ]
[ ] [ ] Shortness of Breath
[ ]Emphysema
[ ] NONE
Initial___
E. Digestive
Had Have
[ ] [ ] Ulcer
[ ] [ ] Constipation
Had Have
Had Have
[ ] [ ] Heartburn [ ] [ ]Diarrhea
[ ] [ ] Food Sensitivies
Had Have
[ ] [ ] Anorexia/Bulimia [ ] NONE
Initial___
F. Sensory
Had Have
[ ] [ ] Blurred vision
[ ] [ ] Loss of taste
Had Have
Had Have
Had Have
[ ] [ ]Ringing ears [ ] [ ]Hearing loss [ ]
[ ] [ ]Chronic ear infection
[ ]Loss of smell
[ ] NONE
Initial___
G. Skin
Had Have
Had Have
[ ] [ ]Skin cancer
[ ] [ ] Hair loss
[]
[]
[ ]Psoriasis
[ ]Rash
Had Have
[]
[ ]Eczema
Had
[]
Have
[ ]Acne
[ ] NONE
Initial___
H. Endocrine
Had Have
[ ] [ ] Thyroid issues
[ ] [ ] Hypoglycemia
Had Have
Had Have
Had Have
[ ] [ ] Low energy [ ] [ ]Swollen glands [ ] [ ] Frequent infection [ ] NONE
[ ] [ ] Immune disorders
Initial___
I. Genitourinary
Had Have
Had Have
Had Have
Had Have
[ ] [ ] Kidney Stones [ ] [ ] Infertility [ ] [ ]Bedwetting
[ ] [ ] Prostate issues
[ ] [ ] Erectile dysfunction
[ ] [ ]PMS symptoms
[ ] NONE
Initial____
J. Constitutional
Had Have
[ ] [ ] Fainting
[ ] [ ] Weakness
Had Have
Had Have
[ ] [ ] Low libido [ ] [ ] Fatigue
[ ] [ ] Sudden weight gain/loss
Had Have
[]
[]
[ ] Poor appetite
[ ] Weakness
[ ] NONE
Initial____
_______________
Doctor’s Initials
Dr. Bea Kilguss
DeSoto Chiropractic
Center
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Past Personal, Family and Social History
Please identify your past health history, including accidents, injuries, illnesses and treatments.
Please complete each section fully.
P
14. Illnesses
Check the illnesses you have HAD in the past or HAVE now.
HAD HAVE
E
R
S
O
N
A
L
____________________
Patient Name
Consultation Notes:
HAD HAVE
[]
[ ] AIDS
[]
[ ] [ ] Allergies
[]
[ ] [ ] Cancer
[]
[ ] [ ] Diabetes
[]
[ ] [ ] Glaucoma
[]
[ ] [ ] Gout
[]
[ ] [ ] Heart disease
[]
[ ] [ ] HIV Positive
[]
[ ] [ ] Measles
[]
[ ] [ ] Mumps
[]
[ ] [ ] Rheumatic fever
[]
[ ] [ ] Sexually transmitted disease
[]
[ ] [ ] Tuberculosis
[]
[ ] [ ] Ulcer
[]
15. Operations
Surgical intervention, which may or may not have
included hospitalization.
[ ] Appendix removal
[ ] Bypass surgery
[ ] Cancer
[ ] Cosmetic surgery ______________________
[ ] Elective surgery _______________________
[ ] Eye surgery ___________________________
[ ] Hysterectomy
[ ] Pacemaker
[ ] Spine ________________________________
[ ] Tonsillectomy
[ ] Vasectomy
[ ] Other________________________________
_____________________________________
_____________________________________
_
_____________________________________
17. Injuries: Have you ever ……..
[ ] Had a fractured or broken bone
[ ] Had a spine or nerve disorder
[ ] Been knocked unconscious
[ ] Been injured in an accident
[ ] Alcoholism
[ ] Arteriosclerosis
[ ] Chicken Pox
[ ] Epilepsy
[ ] Goiter
[ ] Gout
[ ] Hepatitis Type ____
[ ] Malaria
[ ] Multiple Sclerosis
[ ] Polio
[ ] Scarlet fever
[ ] Stroke
[ ] Typhoid fever
[ ] Other_______________
16. Treatments
Check the ones you’ve received in the
PAST or are receiving CURRENTLY.
PAST
CURRENTLY
[]
[ ]Acupuncture
[]
[ ]Antibiotics
[]
[ ]Birth Control Pills
[]
[ ]Blood Transfusions
[]
[ ]Chemotherapy
[]
[ ]Chiropractic care
[]
[ ]Dialysis
[]
[ ]Herbs
[]
[ ]Homeopathy
[]
[ ]Hormone replacement
[]
[ ]Inhaler
[]
[ ]Massage Therapy
[]
[ ]Physical Therapy
[]
[ ]Nutrition Supplements
List:______________________________
__________________________________
____________________________________
[ ] Used a crutch or other support
[ ] Used a neck or back brace
[ ] Received a tattoo
[ ] Had a body piercing
List all Medications (Prescription and over the counter:
F
A
M
I
L
Y
18. Family History. Some health issues are hereditary. Tell Dr. Kilguss about your families health.
Relative
Age (If living) State of Health
Illness
Age at Cause of death
_________________________________________________________________________________
Good
Poor
Death Natural Illness
Mother
Father
Sister 1
Sister 2
Brother 1
Brother 2
________
____
____
____
____
____
____
____
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
___________________ ____
___________________ ____
___________________ ____
___________________ ____
___________________ ____
___________________ ____
___________________ ____
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
_______________
Doctor’s Initials
Dr. Bea Kilguss
DeSoto Chiropractic
Center
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19. Are there any other hereditary health issues that you know about?____________________________
Consulatation Notes:
________________________________________________________________________________________
20. Social History: Your health habits and stress levels.
21.
Alcohol use [ ] Daily [ ] Weekly How Much?______________Prayer/meditation? [ ] Yes [ ] No
Coffee use [ ] Daily [ ] Weekly How Much?______________Job pressure/stress [ ] Yes [ ] No
Tobacco use [ ] Daily [ ] Weekly How Much?______________Financial peace? [ ] Yes [ ] No
Exercising [ ] Daily [ ] Weekly How Much?______________Vaccinated?
[ ] Yes [ ] No
Pain relievers[ ] Daily [ ] Weekly How Much?______________Mercury fillings? [ ] Yes [ ] No
Soft drinks [ ] Daily [ ] Weekly How Much?______________Recreational drugs [ ] Yes [ ] No
Water intake [ ] Daily [ ] Weekly How Much?______________
Hobbies__________________________________________________________________________
Activities of Daily Living. How does this condition currently interfere with your life and ability to function?
No
Mild Mod Severe
No
Mild Mod
Severe
Effect Effect Effect Effect
Effect Effect Effect Effect
Sitting…………………..[ ]…….[ ]……..[ ]……..[ ]
Grocery shopping…….[ ]……[ ]…….[ ]……...[ ]
Rising out of chair……..[ ]…….[ ]…….[ ]……...[ ]
Household chores…….[ ]……[ ]……..[ ]……..[ ]
Standing………………..[ ]…….[ ]…….[ ]……...[ ]
Lifting objects………...[ ]……[ ]…….[ ]….…..[ ]
Walking………………...[ ]……[ ]……..[ ]……...[ ]
Reaching overhead…...[ ]……[ ]…….[ ]……...[ ]
Lying down…………….[ ]…….[ ]…….[ ]……...[ ]
Showering or bathing...[ ]……[ ]…….[ ]……...[ ]
Bending Over……….....[ ]…….[ ]……..[ ]……...[ ]
Dressing myself……….[ ]……[ ]…….[ ]……...[ ]
Climbing stairs………...[ ]…….[ ]…….[ ]……...[ ]
Love life……………….[ ]……[ ]…….[ ]……...[ ]
Using a computer……...[ ]…….[ ]…….[ ]……...[ ] Getting to sleep………..[ ]……[ ]…….[ ]……...[ ]
Getting in/out of car…..[ ]……..[ ]…….[ ]……...[ ] Staying asleep…………[ ]……[ ]…….[ ]……...[ ]
Driving a car…………..[ ]……..[ ]…….[ ]……...[ ] Concentrating…………[ ]……[ ]…….[ ]……...[ ]
Looking over shoulder..[ ]……..[ ]…….[ ]…..….[ ] Exercising……………..[ ]……[ ]…….[ ]……...[ ]
Caring for family……...[ ]……..[ ]…….[ ]……...[ ] Yard work……………..[ ]…….[ ]…….[ ]……..[ ]
_______________
Doctor’s Initials
Dr. Bea Kilguss
DeSoto Chiropractic
Center
22. What is the major stressor in your life?____________________________________________________________________________
23. How much sleep do you average per night?__________________hours.
24. What is the type and approximate age of your mattress and pillow?____________________________________________________
25. What is your preferred sleeping position?__________________________________________________________________________
26. Describe your typical eating habits: [ ]Skip breakfast [ ] Two meals daily [ ] Three meals daily [ ] Snacking between meals
27. What would be the most significant thing that you could do to improve your health?______________________________________
28. In addition to the main reason for your visit today, what additional health goals do you have?______________________________
Acknowledgements: To set clear expectations, improve communications and help you get the best results in the shortest amount of
time, please read each statement and initial your agreement.
____I instruct the chiropractor to deliver the care that, in his or her professional judgment, can best help me in the restoration of my
health. I also understand that the chiropractic care offered in this practice is based on the best available evidence and designed to
reduce or correct vertebral subluxation. Chiropractic is a separate and distinct healing art from medicine and does not proclaim to
cure any named disease or entity.
____I may request a copy of the Privacy Policy and understand it describes how my personal health information is protected and
released on my behalf for seeking reimbursement from any involved third parties.
____I realize that an X-ray examination may be hazardous to an unborn child and I certify that to the best of my knowledge I am not
pregnant. Date of last menstrual period.__________________
____I grant permission to be called to confirm or reschedule an appointment and to be sent occasional cards, letters, emails or health
information to me as an extension of my care in this office.
____I acknowledge that any insurance I may have is an agreement between the carrier and me and that I am responsible for the
payment of any covered or non covered services I receive.
____To the best of my ability, the information I have supplied is complete and truthful. I have not misrepresented the presence,
severity or cause of my health concern.
If the patient is a minor child, print child’s full name:___________________________________________
____________________________________
Signature
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