Young Chiropractic - Chiropractor In Canandaigua, NY USA

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In order to provide you the best possible wellness care, please complete this form

Patient Data

First Name *

Last Name *

Date

Email (Your email will NOT be shared with any 3d parties, and is used for occasional office announcements and promotions.) *

Mailing Address

Address

City

State

Zip

Telephone (Home)

Telephone (Work)

Referred By

Age

Birth Date

Social Security #

Number of Children

Occupation

Employer

Marital Status

Spouse's Name

Spouse's Occupation

Spouse's Employer

Spouse's Health Status

Emergency Contact

Phone

Current Complaints

Nature of Injury

Automobile*

Work

Other

Please Describe

Date of Injury

Date Symptons Appeared

Have you ever had same condition?

NoYes

If yes, when?

List other practioners seen for this injury/condition

Have you ever been under chiropractic care?

NoYes

If yes, please describe

Insurance Information

Name of party responsible for payment

Phone

Do you have health insurance?

NoYes

Name of company

*If an auto accident, please provide:

Insurance company name

Contact person

Phone

Claim #

Medical History

Have you been treated for any conditions in the last year?

NoYes

If yes, please describe

Date of last physical exam

Is there a chance that you are pregnant?

NoYes

Have you had X-rays taken?

NoYes

If Yes, where?

What medications are you taking and for what conditions (Please list dosage and amounts, etc).

What vitamins, minerals, or herbs do you currently take? (Please list for what condition, dosage, and frequency).

Have you ever:

Broken bones?

NoYes

Briefly explain

Been hospitalized?

NoYes

Briefly explain

Been in auto accident?

NoYes

Briefly Explain

Had Sprains/Strains?

NoYes

Briefly explain

Been struck unconscious?

NoYes

Briefly explain

Had surgery?

NoYes

Briefly explain

Family History

Family members - Present and past health conditions (Example: heart disease, cancer, diabetes, arthritis, etc.)

Do you experience pain every day?

NoYes

Do your symptoms interfere with daily life?

NoYes

Does pain wake you up at night?

NoYes

Are your symptoms worse during certain times of the day?

NoYes

Do changes in weather affect your symptoms?

NoYes

Do you wear orthotics?

NoYes

Do you take vitamin supplements?

NoYes

What activities aggravate your symptoms?

Habits

Alcohol

NoneLightModerateHeavy

Coffee

NoneLightModerateHeavy

Tobacco

NoneLightModerateHeavy

Drugs

NoneLightModerateHeavy

Exercise

NoneLightModerateHeavy

Have you ever suffered from:

....

Alcoholism Allergies Anemia Arteriosclerosis Arthritis Asthma Back Pain Breast Lump Bronchitis Bruise Easily Cancer Chest Pain Cold Extremities Constipation Cramps Depression Diabetes Digestion Problems Dizziness Ears Ring Excessive Menstruation Eye Pain or Difficulties Fatigue Frequent Urination Headache Hemorrhoids High Blood Pressure Hot Flashes Irregular Heart Beat Irregular Cycle Kidney Infection Kidney Stones Loss of memory Loss of balance Loss of smell Loss of taste Lumps In Breast Neck Pain or Stiffness Nervousness Nosebleeds Pacemaker Polio Poor Posture Prostate Trouble Sciatica Shortness of breath Sinus Infection Sleep problems or Insomnia Spinal Curvatures Stroke Swelling of ankles Swollen Joints Thyroid Condition Tuberculosis Ulcers Varicose Veins Venereal Disease Other

Other

Enter the verification code in the box below.

Verification Code: *

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Patient Data

Mailing Address

Current Complaints

Insurance Information

Medical History

Have you ever:

Family History

Habits

Have you ever suffered from:

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