M.W.Th. 7 to 5 | Tue. 2 to 6
102 Maple Ave Rochelle, IL 61068
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Demo1

YesNo
MaleFemale
SingleMarriedDivorcedWidowedSeparated
YesNo
Home PhoneCell PhoneWork PhoneEmail
SelfSpouseParent
YesAn accident or injury
WorkAutoOther
YesA worsening long-term problem
WellnessOther
(When did you first notice your symptoms?)
(How extreme are your symptoms?)
(When did it start/how often to you feel it?)ConstantComes & goes, How often?
(What does it feel like?)NumbnessTinglingStiffnessDullAchingCrampsNaggingSharpBurningShootingThrobbingStabbingOther
(Where does it hurt?)
What lessens the problem?
What worsens the problem?
(What have you done to relieve the symptoms?)Rx MedsSurgeryIceOTC drugsAcupunctureHeatMassageChiropracticPTHomeopathic RemediesOtherNone
Work or career?
Recreational activities?
Household responsibilities?
Personal relationships?

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

Musculoskeletal:
None
HadHave
HadHaveOsteoporosis
HadHaveArthritis
HadHaveScoliosis
HadHaveNeck Pain
HadHaveBack Problems
HadHaveHip Disorders
HadHaveKnee injuries
HadHaveFoot/ankle pain
HadHaveShoulder problems
HadHaveElbow/wrist pain
HadHaveTMJ issues
HadHavePoor posture
Sensory:
None
HadHave
HadHaveBlurred vision copy
HadHaveRinging in ears copy
HadHaveHearing loss copy
HadHaveChronic ear infection
HadHaveLoss of smell
Neurological:
None
HadHave
HadHaveAnxiety
HadHaveDepression
HadHaveHeadache
HadHaveDizziness
HadHavePins and Needles
HadHaveNumbness
Endocrine:
None
HadHave
HadHaveThyroid issues
HadHaveImmune disorders
HadHaveHypoglycemia
HadHaveFrequent infection
HadHaveSwollen glands
HadHaveLow energy
Cardiovascular:
None
HadHave
HadHaveHigh Blood Pressure
HadHaveLow Blood Pressure
HadHaveHigh Cholesterol
HadHavePoor Circulation
HadHaveAngina
HadHaveExcessive bruising
Genitourinar:
None
HadHave
HadHaveKidney stones
HadHaveInfertility
HadHaveBedwetting
HadHaveProstate issues
HadHaveErectile dysfunction
HadHavePMS symptoms
Respiratory:
None
HadHave
HadHaveAsthma
HadHaveApnea
HadHaveEmphysema
HadHaveHay fever
HadHaveShortness of breath
HadHavePneumonia
Consitutional:
None
HadHave
HadHaveFainting
HadHaveLow libido
HadHavePoor appetite
HadHaveFatigue
HadHaveSudden weight loss/gain
HadHaveWeakness

Please identify your past health history, including accident,

None Check those you have Had or Have
HadHave
HadHaveAIDS
HadHaveAlcoholism
HadHaveAllergies
HadHaveArteriosclerosis
HadHaveCancer
HadHaveChicken pox
HadHaveDiabetes
HadHaveEpilepsy
HadHaveGlaucoma
HadHaveGoiter
HadHaveGout
HadHaveHeart Disease
HadHaveHIV positive
HadHaveMalaria
HadHaveMeasles
HadHaveMultiple Sclerosis
HadHaveMumps
HadHavePolio
HadHaveRheumatic fever
HadHaveScarlet fever
HadHaveSTD
HadHaveStroke
HadHaveTuberculosis
HadHaveTyphoid fever
HadHaveUlcer
Surgical interventions which may or may not have included hospitalization
YesAppendix removal
YesBypass surgery
YesCancer
YesCosmetic surgery
YesElective surgery
YesEye Surgury
YesHysterectomy
YesPacemaker
YesSpine
YesTonsillectomy
YesVasectomy
Yes2Other
None Past or are receiving Currently
PastCurrently
PastCurrentlyAcupuncture
PastCurrentlyAntibiotics
PastCurrentlyBirth control pills
PastCurrentlyBlood transfusions
PastCurrentlyChemotherapy
PastCurrentlyChiropractic care
PastCurrentlyDialysis
PastCurrentlyHerbs
PastCurrentlyHomeopathy
PastCurrentlyHormone replacement
PastCurrentlyInhaler
PastCurrentlyMassage therapy
PastCurrentlyPhysical therapy
PastCurrentlyNutritional supplements
PastCurrentlyMedications: (Rx or OTC)
None Have you ever . . .
YesHad a fractured or broken bone
YesHad spine or nerve disorder
YesBeen injured in an accident
YesUsed neck or back bracing
YesUsed a crutch
YesBeen unconscious
YesReceived a tattoo
YesHad a body piercing
Some health issues are hereditary. Please tell us about the health of your immediate family members.
Mother
Father
Sister 1
Sister 2
Brother 1
Brother 2
GoodPoor
GoodPoor
GoodPoor
GoodPoor
GoodPoor
GoodPoor
GoodPoor
NatureIllness
NatureIllness
NatureIllness
NatureIllness
NatureIllness
NatureIllness
NatureIllness
Tell us about your health habits and stress levels..
Alcohol useDailyWeeklyNone
Coffee useDailyWeeklyNone
Tobacco useDailyWeeklyNone
ExercisingDailyWeeklyNone
Pain relieversDailyWeeklyNone
Soft drinksDailyWeeklyNone
Water intakeDailyWeeklyNone
PrayerYesNo
Job stress YesNo
Financial peaceYesNo
VaccinatedYesNo
Mercury fillingsYesNo
Recreation drugsYesNo
How does this condition currently interfere with your life and ability to function?
No EffectMid EffectModerate EffectSevere Effect
Grocery shoppingNo EffectMid EffectModerate EffectSevere Effect
Household choresNo EffectMid EffectModerate EffectSevere Effect
StandingNo EffectMid EffectModerate EffectSevere Effect
WalkingNo EffectMid EffectModerate EffectSevere Effect
Lying downNo EffectMid EffectModerate EffectSevere Effect
Bending overNo EffectMid EffectModerate EffectSevere Effect
Climbing stairsNo EffectMid EffectModerate EffectSevere Effect
Using a computerNo EffectMid EffectModerate EffectSevere Effect
Getting in/out of caNo EffectMid EffectModerate EffectSevere Effect
Driving a carNo EffectMid EffectModerate EffectSevere Effect
Looking over shoulderNo EffectMid EffectModerate EffectSevere Effect
Caring for familyNo EffectMid EffectModerate EffectSevere Effect
No EffectMid EffectModerate EffectSevere Effect
SittingNo EffectMid EffectModerate EffectSevere Effect
Rising from chairNo EffectMid EffectModerate EffectSevere Effect
Lifting objectsNo EffectMid EffectModerate EffectSevere Effect
Reaching overheadNo EffectMid EffectModerate EffectSevere Effect
Showering/ BathingNo EffectMid EffectModerate EffectSevere Effect
Dressing myselNo EffectMid EffectModerate EffectSevere Effect
Love lifeNo EffectMid EffectModerate EffectSevere Effect
Getting to sleepNo EffectMid EffectModerate EffectSevere Effect
Staying asleepNo EffectMid EffectModerate EffectSevere Effect
ConcentratingNo EffectMid EffectModerate EffectSevere Effect
ExercisingNo EffectMid EffectModerate EffectSevere Effect
Yard workNo EffectMid EffectModerate EffectSevere Effect
Skip breakfast2 meals a day3 meals a daySnacking between meals
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. Initials

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 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 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 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, 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 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 presence, severity, or cause of my health concerns.

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