REGISTRATION FORM SHEA FAMILY CHIROPRACTIC 858-312-5066

10720 THORNMINT ROAD SUITE B, SAN DIEGO CA 92127

PERSONAL INFORMATION

LAST NAME: ________________________________________________________________________

FIRST NAME: ___________________________________________________ MI: _________________

GENDER: MALE / FEMALE BIRTHDAY: _________ /_________ /_________ AGE: ________

SOCIAL SECURITY NUMBER: ________________________________________________________________________

MARITAL STATUS: SINGLE MARRIED DIVORCED SEPERATED WIDOWED

SPOUSES NAME: ________________________________________________________________________

EMERGENCY CONTACT: NAME: _____________________________ PHONE: _____________________________

WHO REFERRED YOU?: _______________________________________________________________________

CONTACT INOFRMATION

ADDRESS: ________________________________________________________________________

CITY: _______________________________________ STATE: ______ ZIP CODE: ___________

HOME PHONE: ________________________________________________________________________

CELL PHONE: ________________________________________________________________________

HOME EMAIL ADDRESS: ________________________________________________________________________

WORK: PHONE:_____________________________ EMAIL: ______________________________

CONDITION INFORMATION

REASON FOR VISIT: ___________________________________________ MARK AREAS OF SYMPTOMS:

DATE SYMPTONS STARTED?: ___________________________________________

GETTING WORSE OR BETTER?: ___________________________________________

RATE PAIN 0-10: ___________________________________________

TYPE OF PAIN: SHARP / DULL / BURNING / CRAMPING / THROBBING

MY PAIN INTERFERES WITH: WORK / SLEEP / DAILY ROUTINE / RECREATION

FREQUENCY OF MY PAIN: CONSTANT / COMES AND GOES

CHIROPRACTIC GOALS?: ________________________________________________________________________

ACCIDENT?: YES / NO AUTO / HOME / WORK / OTHER ________________________________

HEALTH HISTORY FORM SHEA FAMILY CHIROPRACTIC 858-312-5066
10720 THORNMINT ROAD SUITE B, SAN DIEGO CA 92127

PATIENT NAME:________________________________________________________________DATE:______________

HEALTH HISTORY
CARE CURRENTLY RECEIVING: CHIROPRACTIC / MASSAGE / MEDICATION / SURGERY / OTHER: ____________________
LAST DATE OF: SPINAL EXAM: _______ XRAY: _______ MRI: _______ BONE SCAN: _________

PLEASE CIRCLE ANY CONDITIONS THAT YOU CURRENTLY SUFFER FROM, AND CHECK ANY THAT YOU PREVIOUSLY HAD:
AIDS/HIV ALCOHOLISM ALLERGY SHOTS ANEMIA ANOREXIA
APPENDICITIS ARTHRITIS ASTHMA BLEEDING BREAST LUMP
BRONCHITIS BULIMIA CANCER CATARACTS CHEMICAL DEPENDENT
CHICKEN POX DIABETES EMPHYSEMA EPILEPSY FRACTURES
GLAUCOMA GOITER GONORRHEA GOUT HEART DISEASE
HEPATITIS HERNIA HERNIATED DISCO HERPES HIGH CHOLESTEROL
KIDNEY DISEASE LIVER DISEASE MEASLES HEADACHES MISCARRIAGE
MONO MS MUMPS OSTEOPOROSIS PACEMAKER
PARKINSONS PINCHED NERVE PNEUMONIA POLIO PROSTATE PROBLEM
PROTHESIS PSYCHIATRIC CARE RHEUMATOID ARTH RHEUMATIC FEVER SCARLET FEVER
STROKE SUICUDE ATTEMPT THYROID PROBLEM TONSILLITIS TB
TUMORS, GROWTHS TYPHOID FEVER ULCERS VAGINAL INFECTIONS VENEREAL DISEASE
WHOOPING COUGH COLDS FLU VIRAL INFECTIONS VISION PROBLEMS
FIBROMYALGIA MIGRAINES OTHER

ACTIVITY
EXERCISE WORK ACTIVITY HABITS
NONE ___ SITTING ___ HOURS A DAY? ____________ SMOKING ___ HOW OFTEN? ____________
MODERATE ___ STANDING ___ HOURS A DAY? ____________ ALCOHOL ___ HOW OFTEN? ____________
DAILY ___ LIGHT LABOR ___ HOURS A DAY? ____________ CAFFINE ___ HOW OFTEN? ____________
EXTREME SPORT ___ HEAVY LABOR ___ HOURS A DAY? ____________ STRESS ___ HOW OFTEN? ____________

INJURIES / SURGERIES
FALLS: _________________________________________________ DATE: _________________
HEAD INJURIES / WHIPLASH: _________________________________________________ DATE: _________________
FRACTURES / DISLOCATIONS: _________________________________________________ DATE: _________________
SURGERIES: _________________________________________________ DATE: _________________
CANCER: _________________________________________________ DATE: _________________

MEDICATIONS / VITAMINS / HERBS / MINERALS

PLEASE LIST ALL MEDICATIONS, VITAMINS, HERBS AND MINERALS THAT YOU ARE CURRENTLY TAKING:
__________________________________________________________________________________________________
__________________________________________________________________________________________________

I HEREBY AUTHORIZE THE DOCTOR; AND/OR HIS ASSOCIATES TO EXAMINE ME, AND TO PERFORM ANY NECESSARY DIAGNOSTIC PROCEDURES,
INCLUDING X-RAY TO FULLY EVALUATE MY CONDITION FOR THE PRESENCE OF VERTEBRAL SUBLUXATION.

PATIENT SIGNATURE: ___________________________________________________________ DATE: _______________