Tel: 919.761.5158
Fax: 919.435.1905
610 Dr. Calvin Jones Hwy, Ste 104
Wake Forest, NC 27587
www.VitalityChiropracticNC.com
Date_____________________
Health History Form
Name___________________________________________ Sex
M
F
Date of Birth__________________
Parent’s names (if under 18)
Age___________
SS# ________________________________
Address_________________________________________ City: _____ ____________________ State_______ Zip______________
Home Phone (_____)_________________Cell Phone (_____)____________________ Bus. Phone (_____)____________________
Cell Carrier
Contact Preference
E-Mail
Occupation________________________________________________ Employer__________________________________________
Emergency Contact Name
Phone
Marital Status  S  M  D  W  L/W
Spouse/Partner ____________________________________
Insurance Company: __________________________________ Group #:___________________ Policy #:______________________
Language (opt’l)
Race (opt’l)
Ethnicity (opt’l)
Whom may we thank for referring you to our office? _______________________________________________
Addressing What Brought You Into This Office:
If you have no symptoms or complaints and are here for Chiropractic Wellness Services, please skip to the “General Health History”.
Health Concerns
Please list your health concerns according to
their severity
Rate of severity
1 = mild
10 = worst
imaginable
When did this
episode start?
If you had this
condition
before, when?
1.
2.
3.
4.
Please mark your area of complaint on the diagram below:
Office Use Only:
Did the problem
begin with an
injury?
1. How often do you experience your symptoms?
□ Constantly (76-100% of the time)
□ Frequently (51-75% of the time)
□ Occasionally (26-50% of the time)
□ Intermittently (1-25% of the time)
4. How would you describe the type of pain?
□ Sharp
□ Numb
□ Dull
□ Tingly
□ Diffuse
□ Sharp with motion
□ Achy
□ Shooting with motion
□ Burning
□ Stabbing with motion
□ Shooting
□ Electric like with motion
□ Stiff
□ Other:___________________
5. How are your symptoms changing with time?
□ Getting Worse
□ Staying the Same
□ Getting Better
6. Using a scale from 0-10 (10 being the worst), how would you rate your problem?
0 1 2 3 4 5 6 7 8 9 10 (Please circle)
7. How much has the problem interfered with your work?
□ Not at all
□ A little bit
□ Moderately
□ Quite a bit
□ Extremely
8. How much has the problem interfered with your social activities?
□ Not at all
□ A little bit
□ Moderately
Quite a bit
□ Extremely
9. Who else have you seen for your problem?
“Limited Scope” Chiropractor (focuses mainly on neck and back pain)
“Wellness” Chiropractor (focuses on health and well being as well as underlying cause of pain and health concerns)
Medical Doctor
Other (i.e.: massage therapist/physical therapist/ ER)
10. How long have you had this problem? ________________________________
11. How do you think your problem began?
___________________________________________________________________________________
12. Do you consider this problem to be severe?
□ Yes
□ Yes, at times
□ No
13. What aggravates your problem?
____________________________________________________________________________________
14. What alleviates (helps) your problem?
____________________________________________________________________________________
15. What concerns you the most about your problem; what does it prevent you from doing?
____________________________________________________________________________________
16. How would you rate your overall Health?
□ Excellent
□ Very Good
□ Good
□ Fair
17. What type of exercise do you do?
□ Stenuous
□ Moderate
□ Light
□ Poor
□ None
18. Indicate if you have any immediate family members with any of the following:
□ Rheumatoid Arthritis
□ Diabetes
□ Lupus
□ Heart Problems
□ Cancer
□ ALS
19. What activities do you do at work?
□ Sit:
□ Most of the day
□ Stand:
□ Most of the day
□ Computer work:
□ Most of the day
□ On the phone:
□ Most of the day
□ Half the day
□ Half the day
□ Half the day
□ Half of the day
□ A little of the day
□ A little of the day
□ A little of the day
□ A little of the day
20. What activities do you do outside of work?_____________________________________________________
□
□
□
□
Is this condition interfering with any of the following:
Work □
Sleep □
Daily routine □
Sports/exercise □
Other □ (please explain):
General Health History
Often times, accumulation of life’s stress can lead to health problems and influence our ability to heal. Please pay close attention to
this as it will help us help you!
List any medications you are currently taking:
___________________________________________________________________________________________________________
List any supplements you are currently taking:
___________________________________________________________________________________________________________
Allergies/ Medication Allergies:
List any surgeries you have had:
List any hospitalizations you have had:
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 Pain
□
□ Upper Leg Pain
□
□ Knee Pain
□
□ Ankle/Foot Pain
□
□ Jaw Pain
□
□ Joint Pain/Stiffness
□
□ Arthritis
□
□ Rheumatoid Arthritis
□
□ Cancer
□
□ Tumor
□
□ Asthma
□
□ Chronic Sinusitis
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
□
□ General Fatigue
□
□ Muscular Incoordination
□
□ Visual Disturbances
□
□ Dizziness
Have you ever received Chiropractic care?
Y
Past Present
□
□ Diabetes
□
□ Excessive Thirst
□
□ Frequent Urination
□
□ Smoking/Tobacco Use
□
□ Drug/Alcohol Dependence
□
□ Allergies
□
□ Depression
□
□ Systemic Lupus
□
□ Epilepsy
□
□ Dermatitis/Eczema/Rash
□
□ HIV/AIDS
For Females Only
□
□ Birth Control Pills
□
□ Hormonal Replacement
□
□ Pregnancy
□
□ Other:_______________________
 N Name of D.C.__________________________________________
Are you interested in knowing more about how your nutrition (food you eat) affects your overall
health and well-being?
Yes
If dietary changes are indicated would you be willing to make changes in your diet?
Yes
Would you take whole food supplements if indicated?
If specific exercises or stretching would help would you consider adding them to your program?
If reducing stress would help you would you like to know ways to reduce stress?
□
□
Yes □
Yes □
Yes □
No
No
No
No
No
□
□
□
□
□
Maybe
□
□
Maybe □
Maybe □
Maybe □
Maybe
Stressors
Because accumulation of stress affects our health and ability to heal please list your top three stresses (you have ever had) in each
category:
1.
Physical stress (falls, accidents, work postures, etc.)
a. _________________________________________________________________________________________
b. _________________________________________________________________________________________
c. _________________________________________________________________________________________
2.
Bio-chemical stress (smoke, unhealthy foods, missed meals, don’t drink enough water, drugs/alcohol, etc.)
a. _________________________________________________________________________________________
b. _________________________________________________________________________________________
c. _________________________________________________________________________________________
3.
Psychological or mental/emotional stress (work, relationships, finances, self-esteem, etc.)
a. _________________________________________________________________________________________
b. _________________________________________________________________________________________
c. _________________________________________________________________________________________
On a scale of 1-10 please grade your present levels of stress (including physical, bio-chemical and psychological or
mental/emotional):
At work:
At home:
At play:
On a scale of 1-10, (1 being very poor and 10 being excellent) please describe your:
Eating habits:
Exercise habits:
How do you grade your physical health?
Excellent □
Good □
Sleep:
General health:
Mind set:
Fair □
Poor □
Getting better □
Getting worse □
How do you grade your emotional/mental health?
Excellent □
Good □
Fair □
Poor □
Getting better □
Getting worse □
Is there anything else which may help to better understand you which has not been discussed?
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Why are you here at this point in time?
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Females:
Are you pregnant?
Y
N
Date of last menstrual period: ____________________________________
If x-rays are recommended, your signature is required (below) to indicate that you are not pregnant.
Signature: ________________________________________________Date:_______________________________
Additional services provided include:
Functional Nutrition Used to address the underlying cause of disease using a system-oriented approach. A whole body, patient centered
analysis is taken to address healthcare concerns. Often times the isolated set of symptoms are diagnosed and treated
overlooking the main cause of the disease state.
Functional nutrition is different than traditional approaches. It is an integrative and science-based approach that is patient
centered with a goal to address and correct the underlying cause; not merely addressing and covering up the symptoms.
ALCAT Testing –
Through ALCAT Worldwide, we are able to determine if you have food sensitivities that could be creating underlying
inflammation in your body.
ALCAT is a tool used to determine if there is chronic activation of the immune system leading to a wide variety of
conditions such as: Digestive Disorders, Migraines, Obesity, Chronic Fatigue, Aching Joints, Skin Disorders, and Autism
to name a few.
Stool and Saliva testing –
An effective way to test for a variety of diseases and conditions. If you are having symptoms of: chronic stress, fatigue,
low testosterone, peri-menopausal symptoms, menopause symptoms, irritability, depression, digestive disorders you may
find this testing helpful for determining the cause of your symptoms.
At Vitality Chiropractic and Family Wellness, we offer lab testing, food allergy testing, hair analysis,
saliva testing and functional nutrition to optimize your health and wellness. Please indicate if you are
interested in learning more about optimizing your health.
Yes
No
About Your Care
There are three phases of care that Chiropractic patients often go through. The first is Initial Intensive Care which corrects the most
recent layer of Spinal and Neurological damage (VSC Vertebral Subluxation Complex). This care often reduces or eliminates the
symptoms. Then you begin Reconstructive Care which corrects the years of damage that occurred when there were few symptoms.
At this point stabilization phase begins. And finally, Chiropractic offers a genuine approach to Wellness Care. All of these phases
will be explained at your report of findings. Then you’ll be able to begin a course of care that fits your goals.
Cancellation/ Broken Appointment Policy
Our commitment to your great chiropractic care begins with a defined schedule in which we have allotted specific amounts of time for
you and other patient abased on your specific needs. With said, we understand that “life” happens and results in needed changes to
our day to day schedule that may prevent us from keeping an appointment. We respectfully request at least 24 hour advanced notice
if you need to cancel an appointment. Giving us as much notice as possible ensures that someone else is able to take advantage of the
time that was allotted to you.
An appointment that is cancelled with less than 24 hours’ notice or an appointment that is not canceled at all in which the patient fails
to appear to is considered a broken appointment. Broken appointments delay the success of your treatment and the treatment of other
patients. Therefore, 3 broken appointments will result in a $25.00 office fee.
Thank you in advanced for your compliance with out cancellation and broken appointment policies. Please know that all policies are
in place to ensure a great chiropractic experience for you and your family. Again, we look forward to serving your every chiropractic
need!
Please initial below that you read and understand the cancellation and broken appointment policy.
Initial Here:
____I consent to a professional and complete chiropractic examination and to any radiographic
examination that the doctor deems necessary.
I understand that any fee for service rendered is due at the time of service and cannot be deferred to a
later date.
Signature______________________________________________________________ Today’s Date_______________________
Signature of Parent (for minor):____________________________________________ Today’s Date_______________________
Thank you for being part of the Vitality Chiropractic Family.
We look forward to serving you.