Webb Clinic of Chiropractic

407-862-8834 Fax 407-862-5951

 Date:
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Name 

 Home Phone  Work Phone 
Address  City  State  Zip
SSN  Sex  Age 
Marital Status  DOB     
 Employer's Name and Address
 Explain Occupation (actual job duties)
 Name of Spouse  Spouse's Employer & Phone 
Nearest Relative Phone of Nearest Relative 
 

 Are you here as a result of an injury? Yes No

 Do you think you might be pregnant? Yes No
 Have you ever seen a Chiropractor?    Yes No  When? Doctor's Name
 Describe your major complaint
 What movements, activities, or positions aggravate this condition?  
 Have you been treated for this condition before?  Yes No
 If yes, when and what was done?
 
PERSONAL HISTORY:
 Illness or Conditions 
 Surgeries
 Fractures  Previous Injuries
 Medications  Supplements
 Last Medical Exam Date  Medical Physician's Name
 Hobbies/Recreational Activities
 
Please check all that apply:  Do you have pain in:
  No symptoms, check-up   Poor Appetite   Neck  
  Headaches   Constipation   Shoulder   Right Left
  Blurred Vision   Loose Stool   Arm   Right Left
  Dizziness   Excessive Gas   Elbow   Right Left
  Low Energy   Heart Palpitations   Hand   Right Left
  Weakness   Sexual Impotency   Upper Back  
  Indigestion/Heartburn   Hot Flashes   Mid Back  
  No symptoms, check-up   Inner tension   Lower Back  
  Throat Lump/Constriction   Menstruation   Hip   Right Left
  Numbness     Thigh   Right Left
  Fainting/Light-headed  Do you have a history of:   Knee   Right Left
  Swelling   Heart Disease   Calf   Right Left
  Sinus Problems   Stroke   Ankle   Right Left
  Insomnia   Kidney Stones   Foot   Right Left
  Poor Memory   Urinary Tract Infection   Chest  
  Excessive Swelling     Abdomen  
 Pain in Morning  Afternoon   Night   Kidney Area  

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  Webb Clinic of Chiropractic 407-862-8834