Chiropractie
Oosterheem
Intake form
Willem Dreeslaan 422
2729NK Zoetermeer Tel: 0793602188
Name:............................................................................
Maidenname:.................................................................
First name:......................................................................
Date of Birth:.............................................................
Address:..........................................................................
Postcode:.......................................................................
City:................................................................................
Phone
private:...........................................................
Phone Work:................................................................
Mobile number:.............................................................
E-mail address:..............................................................
Referred by: GP / doctor / family / acquaintance / other
Are you: Married / Single
Children:................../ grandchildren:.....................
Insurance company +
number:...................................................................
Name of GP:...................................................................
Profession:.......................................................................
Are you able to work at this moment?
Yes / No / Company doctor / enabled ARBO
Hobbies/sports:................................................................
.......................................................................................
Social Security number:....................................................
What is the most important
Becomes worse when:
complaint:
sitting
........................................................
walking
........................................................
standing
........................................................
bending over
When did it start:
lying down
........................................................
moving
turning the head
How did it start:
sneezing/coughing
Gradually
other activities /
variably present
positions
always present
.............................................................
Acute
Lessens when:
variably present
always present
sitting
walking
Is there any radiation towards:
standing
arm Left / Right
bending over
leg Left / Right
lying down
moving
other activities/positions
.............................................................
Please indicate where the
complaint occurs
Experts:
Have you been treated for this
condition by:
o Chiropractor:................................
o GP:..............................................
o Physiotherapist:............................
o Cesar/mensendieck:....................
o Manual therapist:........................
o Podiatrist:…….............................
o Neurologist:..................................
o Rehab. doctor:...............................
o Rheumatologist:............................
o Acupuncturist:...............................
o Surgeon:........................................
o Pain clinic:.....................................
o Homeopathic dr.:….....................
o Orthopedist:...................................
o Psychologist:................................
o Alternative healer:.......................
o Other:.........................................
........................................................
Your medical situation
previous issues
previous issues
current issues
current issues
Muscles and Joints
General
Neck
Head ache
Migraine
Between the shoulders
Dizziness
Lower back
Fainting
Tailbone
Tinnitus L/R
Groin L/R
Insomnia
Hip L/R
Exhaustion
Leg L/R
Nervousness
Knee L/R
Allergies
Foot or heel L/R
Depression
Shoulder L/R
Jaw ache L/R
Arm L/R
Low appetite
Elbow L/R
Ear, nose, eye and/or throat
Hand L/R
Sinus inflammation
Wrist L/R
Sinusitis
Fingers L/R
Ear infection L/R
Rib L/R
Deafness L/R
Inflamed joints
Swollen joints
p.t.o.
Arthritis
Gout

previous issues
current issues
Heart and vessels
Heart issues
Stroke
previous issues
current issues
Women
Menopause issues
Menstrual cramps
Back pain during menses
Irregular menses
Excessive blood loss
previous issues
current issues
Stomach and
intestines
Stomach ache
Stomach ulcers
Stomach rupture
Bile problems
Liver problems
High blood pressure
Low blood pressure
Varicose veins L/R
Bad circulation
Swelling in ankles L/R
Anemia
Breathing
Breathing difficulties
Asthma
Bronchitis
Pneumonia
Emphysema
Hay fever
Pain in chest
Chronic coughing
Coughing up blood
Coughing up slime
Have you ever miscarried?
Constipation/difficult
bowel movement
Are you possibly pregnant?
When did you menstruate
last:..............................
Other
..........................................................
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..........................................................
..........................................................
..........................................................
..........................................................
..........................................................
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..........................................................
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Diarrhea
Vomiting
Hemorrhoids
Flatulence
Bladder issues
Kidney infection
Prostate problems
Urinary incontinence
Appendicitis
Skin
Itchiness
Eczema
Bruising
Dry skin
Conditions
Angina Pectoris
Alcoholism
Epilepsy
Cancer
Multiple sclerosis
Polio
Meningitis
Rheumatism
Tuberculosis
Diabetes
Pfeiffer’s disease
Thyroid disorder
Other:
........................................
..........................................................
Date of your last tests
Urine test
X-rays/CT/MRI
Blood test
Chiropractic examination
Heart examination
Habits
Shorter than
6 mnth
A lot
Dental
Do you grind or clench your
teeth during day / night
Do you use partial or complete
dentures
Do your jaws ever feel tired in
the morning?
Do you have crowns
Do you have a bridge
Do you have a frame or a
plate in your mouth
Have you had braces
Does your jaw joint ever
make a cracking sound
between 618 mnth
longer than
18 mnth
normal
little
never
Do you use:
Orthotics
Lift (heel) L/R
Others
How do you sleep:
Back
Side
Belly
Variable
How old is your matrass..................
.........................................................
Is your matrass comfortable:
Yes
No
Do you have any comments:
none
Appetite
Coffee
Alcohol
Exercise
Sleep
Smoking
Accidents..............................
Operations:................................
Mental illness:......................
Bone breaks..............................................
Hospitalizations:……...............................
Medication used and
reason:.........................................................................................................
.........................................................................................................................
Signature:...............................
Date:...........................................