Please describe your Primary Complaint in the space below. Use the Secondary and Additional Complaint boxes if they apply. Location (Where does it hurt?) Primary Complaint Secondary Complaint Additional Complaint Circle the area(s) on the The primary symptom that prompted me to seek care The secondary symptom that prompted me to seek care The additional symptom that prompted me to seek care illustration. today is: today is: today is: “0” for current condition “X” for conditions experienced in the past And are the result of (darken circle): And are the result of (darken circle): And are the result of (darken circle): An accident or injury An accident or injury An accident or injury Work Auto Other Work Auto Other Work Auto Other A worsening long-term problem A worsening long-term problem A worsening long-term problem An interest in: Wellness Other An interest in: Wellness Other An interest in: Wellness Other Onset (When did you first notice your current Onset (When did you first notice your current Onset (When did you first notice your current symptoms?) symptoms?) symptoms?) Prior interventions (What have you done to relieve Prior interventions (What have you done to relieve Prior interventions (What have you done to relieve the symptoms?) the symptoms?) the symptoms?) Prescription medication Acupuncture Prescription medication Acupuncture Prescription medication Acupuncture Over-the-counter drugs Chiropractic Over-the-counter drugs Chiropractic Over-the-counter drugs Chiropractic Homeopathic remedies Massage Homeopathic remedies Massage Homeopathic remedies Massage Physical therapy Ice Physical therapy Ice Physical therapy Ice Surgery Heat Surgery Heat Surgery Heat Other Other Other 1. What else should Dr. Cheatwood know about your current condition? 2. How does your current condition interfere with your: Work or career: Recreational activities: Household responsibilities: Personal relationships: 3. Review of Systems Chiropractic care focuses on the integrity of your nervous system, which controls and regulates your entire body. Please darken the circle beside any condition that you’ve Had or currently Have and initial to the right. a. Musculoskeletal Had Have Had Have Had Have Had Have Had Have Had Have NONE Osteoporosis Arthritis Scoliosis Neck pain Back problems Hip disorders Knee injuries Foot/ankle pain Shoulder problems Elbow/wrist pain TMJ issues Poor posture Initials b. Neurological Had Have Had Have Had Have Had Have Had Have Had Have NONE Anxiety Depression Headache Dizziness Pins and Numbness needles Initials c. Cardiovascular Had Have Had Have Had Have Had Have Had Have Had Have NONE High blood Low blood High cholesterol Poor circulation Angina Excessive pressure pressure bruising Initials Patient name d. Respiratory Had Have Had Have Had Have Had Have Had Have Had Have NONE Asthma Apnea Emphysema Hay fever Shortness Pneumonia Patient Number of breath Initials e. Digestive (office use only) Had Have Had Have Had Have Had Have Had Have Had Have NONE Anorexia/bulimia Ulcer Food sensitivities Heartburn Constipation Diarrhea Doctor’s Initials Initials f. Sensory Had Have Had Have Had Have Had Have Had Have Had Have NONE Janice A Cheatwood, DC Blurred vision Ringing in ears Hearing loss Chronic ear Loss of smell Loss of taste Initials g. Skin infection Had Have Had Have Had Have Had Have Had Have Had Have NONE Skin cancer Psoriasis Eczema Acne Hair loss Rash PAGE Initials Version No. 222993737 2/4 © 2015 Paperwork Project. All rights reserved. (Continued from previous page) h. Endocrine Had Have Had Have Had Have Had Have Had Have Had Have NONE Thyroid issues Immune Hypoglycemia Frequent Swollen glands Low energy Patient name disorders infection Initials i. Genitourinary Had Have Had Have Had Have Had Have Had Have Had Have NONE Kidney stones Infertility Bedwetting Prostate issues Erectile PMS symptoms Patient Number dysfunction Initials (office use only) j. Constitutional Had Have Had Have Had Have Had Have Had Have Had Have NONE Fainting Low libido Poor appetite Fatigue Sudden weight Weakness All other systems negative gain/loss (circle one) Initials Past Personal, Family and Social History Please identify your past health history, including accidents, injuries, illnesses and treatments. Please complete each section fully. 4. Illnesses 5. Operations 6. Treatments Check the illnesses you have Had in the past or Have now. Surgical interventions, which may or Check the ones you’ve received in the Had Have Had Have may not have included hospitalization. Past or are receiving Currently. AIDS Tuberculosis Appendix removal Past Currently Alcoholism Typhoid fever Bypass surgery Acupuncture Allergies Ulcer Cancer Antibiotics Arteriosclerosis Other: Cosmetic surgery Birth control pills Cancer Elective surgery: Blood transfusions Chicken pox Chemotherapy 7. Allergies Diabetes Eye surgery Chiropractic care Are you allergic to any medications? Epilepsy Hysterectomy Dialysis Yes No Glaucoma Pacemaker Herbs If Yes please list: Goiter Spine Homeopathy Gout Hormone replacement Heart disease Inhaler Hepatitis Tonsillectomy Massage therapy PERSONAL HIV Positive Vasectomy Physical therapy Malaria Other: Medications Measles (Please list below all prescription, over-the-counter, natural supplements, enzymes, vitamins and Multiple Sclerosis minerals): Mumps 8. Injuries Polio Have you ever... Rheumatic fever Had a fractured or broken bone Used a crutch or other support Scarlet fever Had a spine or nerve disorder Used neck or back bracing Sexually transmitted disease Been knocked unconscious Received a tattoo Consultation Notes Stroke Been injured in an accident Had a body piercing 9. Family History Some health issues are hereditary. Tell Dr. Cheatwood about the health of your immediate family members. Relative Age (If living) State of health Illnesses Age at death Cause of death Good Poor Natural Illness Mother Father Sister 1 Sister 2 FAMILY Brother 1 Brother 2 10. Are there any other hereditary health issues that you know about? 11. Social History Tell Dr. Cheatwood about your health habits and stress levels. Alcohol use Daily Weekly How much? Prayer or meditation? Yes No Coffee use Daily Weekly How much? Job pressure/stress? Yes No Tobacco use Daily Weekly How much? Financial peace? Yes No Doctor’s Initials Exercising Daily Weekly How much? Vaccinated? Yes No Pain relievers Daily Weekly How much? Mercury fillings? Yes No Janice A Cheatwood, DC SOCIAL Soft drinks Daily Weekly How much? Recreational drugs? Yes No Water intake Daily Weekly How much? PAGE Hobbies: Version No. 222993737 3/4 © 2015 Paperwork Project. All rights reserved. 12. Activities of Daily Living How does this condition currently interfere with your life and ability to function? No Mild Moderate Severe No Mild Moderate Severe Patient name Effect Effect Effect Effect Effect Effect Effect Effect Sitting Grocery shopping Rising out of chair Household chores Patient Number (office use only) 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 13. What is the major stressor in your life? 14. How much sleep do you average per night? Hours 15. What is the type and approximate age of your mattress and pillow? 16. What is your preferred sleeping position? 17. Describe your typical eating habits: Skip breakfast Two meals a day Three meals a day Snacking between meals 18. What would be the most significant thing that you could do to improve your health? 19. In addition to the main reason for your visit today, what additional health goals do you have? Acknowledgements Consultation Notes 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 judgement, 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 Initials 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 Initials 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 Initials the best of my knowledge I am not pregnant. Date of last menstrual period (MM/DD/YYYY): I grant permission to be called to confirm or reschedule an appointment and to be sent occasional cards, letters, Initials 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 Initials 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 Initials presence, severity or cause of my health concern. Doctor’s Initials Janice A Cheatwood, DC Patient (or Guardian’s) signature Date (MM/DD/YYYY) PAGE Version No. 222993737 4/4 © 2015 Paperwork Project. All rights reserved..