1. health and fitness
2. disease
3. headaches and migraines

Matthew J. Lieber, D.C., LLC
Confidential Patient Data
(Please complete this form in full. If you need any assistance, we would be happy to help)
General Information
Today's Date: _______________
Name: _______________________________________________________________________________
Address: _____________________________________________________________________________
City: _____________________________________________
State: ________
Zip: ____________
Home Phone: _________________________
Please call me at:
home
Work Phone: __________________________
Please call me at:
work
Cell Phone: ___________________________
Please call me at:
cell
 Email Address: ____________________________________________________________
Sex:
 Male
 Female
Marital Status:
 Married
Single
Divorced
Separated
Other ___________
Birth Date: ________________________________________
Number of Children: _________________________________
Name of Nearest Relative: ________________________________
Phone: ____________________
Current Occupation: _____________________________________________________________________
Employer Name: ________________________________________________________________________
Employer Address: ______________________________________________________________________
How were you referred to this office?
Friend/Family Member – Name: ____________________________________________________
Yellow Pages ad Mail
 Website
Passing By
Other_______________
Payment Information (please check)
Self
Spouse
 Other: _______________________________
Insurance
Self-Pay
HMO
 PPO
 POS
 EPO
 HSA/HSP
Auto Insurance
Worker's Compensation
“Health” Insurance Information:
Social Security #: ____________ - _________ - ____________ (we require your SS # to file any insurance)
Insurance ID #: ______________________________________ (if your ID # is not your SS #)
Group ID #: _________________________________________
Special ID #: ________________________________________
Responsible Party:
Payment for Services:
If Insurance:
Primary or Auto Insurance Name: ____________________________________ Phone #: _________________
Primary or Auto Insurance Address: ____________________________________________________________
Secondary Insurance Name: _______________________________________ Phone #: _________________
Secondary Insurance Address: ________________________________________________________________
Additional “Auto/Worker’s Compensation” Insurance Information:
Claim #: ____________________________________________
Injury/Loss Date: _____________________________________
Adjuster Name (for Auto/Workers Comp): _____________________________ Phone #: _________________
Lawyers Name (for Auto Accident): __________________________________ Phone #: _________________
Lawyers Address: __________________________________________________________________________
1
Matthew J. Lieber, D.C., LLC
677 Tomlinson Lane * Yardley * PA * 19067
215-436-7227
Chiropractic Information:
Yes
Have you had previous Chiropractic Care?
No
If yes? Date of Last Visit: ___________
If Yes:
Chiropractor Name and Location: ___________________________________________
If Yes:
Response to care?
No Results
Positive Results
Negative Results
Has anyone explained Chiropractic to you?
Yes
No
Have you had Spinal X-rays or MRI’s taken?
Yes
No
If yes? Date Films Taken: ___________
Yes
No
If yes? Date of Last Visit: ___________
Massage Information:
Have you had previous Massage Care?
If Yes:
Therapist Name and Location: ___________________________________________
If Yes:
Response to care?
No Results
Positive Results
Negative Results
General Health History: (please check)
Yes
Do you feel as if you're in control of your life and health?

Excellent
Please rate your overall health:
Please describe your overall health situation:
Current Health Practices:
(check all that apply)
Improving
No
Good
Fair
No Change
Poor
Worsening
Walking
Jogging
Biking
Hiking
Supplements
Homeopathy
Herbs
Aryuvedic
Circuit Training
Weight Lifting
Aerobics
Swimming
Yoga/Pilates
Stretching
Tai Chi
Chi gong
Massage
Reflexology
Meditation
Biofeedback
Special Diet: _________________________________________________________
Supplements: ________________________________________________________
Current Sports: _______________________________________________________
Water Consumption: ___________________________________________________
Family History:
M






F






M = Mother, F = Father (Please check appropriate boxes for your parents)
M






Deceased
Anemia
Auto-Immune diseases
Bad Circulation
Bladder Trouble
Cancer
F






Diabetes
Epilepsy/Convulsions
Hepatitis
Heart Trouble
High Blood Pressure
Kidney Disorder
M






F






Muscular Dystrophy
Polio
Spinal Problems
Multiple Sclerosis
Stroke or CVA’s
Tuberculosis
Social History: (please check)
Tobacco usage
Alcohol usage
Drug usage
Exercise
Sleep
None
None
None
Never

Soundly
Light
Light
Light
Seldom
Lightly
Moderate
Moderate
Moderate
Occasional
Restlessly
Heavy

Heavy

Heavy
Never
Rarely
# Hrs: _______
Dr. Notes: ________________________________________________________________________________________
__________________________________________________________________________________________
2
Matthew J. Lieber, D.C., LLC
677 Tomlinson Lane * Yardley * PA * 19067
215-436-7227
GENERAL Review of Systems: (Please check the appropriate “Yes,” “No” or “Past” for each of the following. Fill in
the blanks where requested. If there are multiple choices per line, circle whichever applies to you)
Constitutional, Sleep & Energy
Fatigue
Recent change in weight
Night sweats
Fever
Feel tired in afternoon
Needs coffee to get started
Can’t fall asleep
Wakes middle of the night
Intense dreams/Nightmares
Need more than 10 hrs of sleep
Skin (cont.)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
Past
Past
Past
Past
Past
Past
Past
Past
Past
Past
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Past
Past
Past
Past
Past
Past
Past
Past
Past
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Past
Past
Past
Past
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Past
Past
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Past
Past
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Past
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
Past
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Past
Past
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Past
Past
Past
Past
Past
Past
Past
Past
Excessive sweating
Body odor
Hair loss
Hives
Eczema
Psoriasis
Shingles
Positive TB test ever?
Asthma
Bronchitis/Pneumonia
Smoker
Live with smokers
Chronic cough
Coughing up phlegm
Coughing up blood
Wheezing
Pain/difficulty breathing
Shortness of breath
Sensitive to smog/pollution
Exposed to chemicals
Ears
Earaches/Ear pain
Discharge from ears
Itchy ears
Excessive wax
Ringing in ears
Hearing loss
Frequent ear infections
Change in appetite
Difficulty swallowing
Belching/burping
Heartburn / Reflux / Gerd
Stomach pain/indigestion
Nausea/Vomiting
Ulcers
Liver/Gallbladder disease
Intolerance to greasy foods
Sensitivity to foods
Fatigue after eating
Gas / Bloating / Cramping
Constipation (<1 BM/day)
3 or more BM/day
Loose stools/diarrhea
Foul smelling stools
Blood/mucous/black tarry stool
Hemorrhoids
Hernias
Chronic Itching
Mouth, Throat & Neck
Mouth/lip sores
Swollen tongue
Wear dentures
Dental/gum problems
Painful chewing
Bleeding gums
Bad breath/taste
Frequent sore throat
Loss of taste
Voice change
Swollen glands
Jaw pain/stiffness
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
Past
Past
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Past
Past
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Past
Past
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Past
Past
Past
Past
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Past
Past
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Past
Past
Past
Past
Past
Past
Past
Past
Past
Past
Musculoskeletal
Muscle weakness
Muscle cramps/soreness
Muscle Jerking
Back pain
Pain/tightness – Neck / Shoulders
Tingling/Burning Hands/Feet
Joint pain or stiffness/Arthritis
Swollen joints
Stiff in the morning
Herniated/Slipped disk
Tendonitis
Double jointed
Bones sore/painful
Loss in height
Osteoporosis
Broken bones
Injure easily
Unable to Walk/Sit properly
Skin
Dry skin
Rashes
Itching
Change in skin color
Yellowing of skin (Jaundice)
Change in hair/nails
Poor wound healing
Bumps on backs of arms
Past
Past
Past
Past
Past
Past
Past
Digestive system
Nose & Sinuses
Frequent nosebleeds
Loss of smell
Itchy nose
Frequent stuffy nose
Must breathe thru mouth
Post nasal drip
Frequent colds
Sinus problems
No
No
No
No
No
No
No
Lungs & Breathing
Eyes
Double vision
Eye Pain
Wear glasses/contacts
Blurred vision
Dry eyes
Itchy/watery eyes
Red/Inflamed eyes
Discharge from eyes
Eyes sensitive to bright light
Yes
Yes
Yes
Yes
Yes
Yes
Yes
3
Matthew J. Lieber, D.C., LLC
677 Tomlinson Lane * Yardley * PA * 19067
215-436-7227
Heart
Endocrine (cont.)
Do aerobic exercise
Known heart trouble
Rapid beating heart
High blood pressure
Low blood pressure
Chest pain/tightness
Can feel heart beating
Heart fluttering
High cholesterol
Swelling of legs/ankles
Heaviness in legs
Tired with minor exertion
Hard to breathe at night
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
Past
Past
Past
Past
Past
Past
Past
Past
Past
Past
Past
Past
Past
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Past
Past
Past
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Past
Past
Past
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Past
Past
Past
Past
Past
Past
Past
Past
Past
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Past
Past
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Past
Past
Past
Past
Past
Past
Yes
Yes
Yes
Yes
No
No
No
No
Past
Past
Past
Past
Calmer after eating
Shaky between meals
Heart palpitation after eating
Crave sweets
Excessive thirst
Excessive hunger
Diabetes
Overweight
Swollen/bulging eyes
Intolerant to heat
Intolerant to cold
Thyroid problems
Temperature below 97.6 f
Gain weight easily
Skin on legs dry
Thinning outside eyebrows
Energized from exercise
Nervous System
Head injury
Diagnosed concussion
Frequent headaches/migraines
Lightheadedness/dizzy
Feeling of spinning/vertigo
Fainting
Numbness/tingling
Loss of memory
Poor concentration
Lack of mental alertness
Loss of balance/uncoordinated
Convulsions/seizures
Depression/Crying Spells
Tremors/trembling hands
Paralysis
Multiple Sclerosis
Stroke
Breasts
Breast pain or tenderness
Breast lumps
Nipple discharge
Regular monthly self exam?
Yes
Yes
Yes
Yes
No
No
No
No
Past
Past
Past
Past
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Past
Past
Past
Past
Past
Past
Past
Past
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Past
Past
Past
Past
Male Reproduction
Testicular lump or pain
Difficult to get/keep an erection
Painful ejaculation
Discharge from penis
Sores on or around pubic area
Prostate problems
Infertility
Low sperm count
Psychological & Emotional
Down/Sad/Blue/Depressed
Anxious/Tense
Suicidal feelings/thoughts
Impatient/Moody/Nervous
Recent Personality Changes
Endocrine
Headaches better by eating
Irritable if meal is missed
Tired/weak if miss a meal
Awaken at night hungry
Past
Past
Past
Past
Past
Past
Past
Past
Past
Past
Past
Past
Past
Past
Past
Past
Past
Vaginal pain/burning/sores
Yes
No Past
Vaginal yeast infections
Yes
No Past
Vaginal discharge
Yes
No Past
Hot flashes/Night sweats
Yes
No Past
Pelvic soreness
Yes
No Past
Bleeding between periods
Yes
No Past
Hysterectomy
Yes
No Past
Osteoporosis
Yes
No Past
Hot flashes/Night sweats
Yes
No Past
Cramping before period
Yes
No Past
Cramping during period
Yes
No Past
Missed periods
Yes
No Past
Before a period:
Yes
No Past
Moodiness/irritability
Yes
No Past
Lumpy or tender breasts
Yes
No Past
Bloating & swelling
Yes
No Past
Craving sweets
Yes
No Past
Low back/abdomen pain
Yes
No Past
Regular cycles
Yes
No Past
Date of last pap smear: _______________________________
Abnormal pap
Yes
No Past
Uterine/Ovarian cysts/fibs
Yes
No Past
Number of pregnancies: ______________________________
Number of live births: ________________________________
Urinary/General reproductive
Frequent urination
Burning/painful urination
Waking to urinate at night
Urgency to urinate
Inability to hold urine
Bedwetting
Dripping after urination
Urination with cough/sneeze
Difficult to stop/start urinating
Blood in urine
Dark urine
Strong smelling urine
Low back pain
Kidney stones
Frequent bladder infections
Antibiotics for infection
Lack of sex drive
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Female Reproduction (if male skip ahead)
Blood, Circulation & Immune
Anemia
Easy bleeding/bruising
Purple fingers/lips
Varicose veins
Deep leg pain
Cold hands/feet
Cuts slow to heal
Frequent infections
Transfusions
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
4
Matthew J. Lieber, D.C., LLC
677 Tomlinson Lane * Yardley * PA * 19067
215-436-7227
Medical History:
Treated by Doctor a/o Therapist for any reason in the last year? Yes
No
If yes, please describe reason: ______________________________________________________________
Date of Last Visit: __________________________
Date of Last Physical: _______________________
Doctor Name & Location: __________________________________________
Phone #: _______________
Yes
No
Reason: _____________________________
Current Medications? (including over the counter meds)
If yes:
Name: _______________________
Name: _______________________
Reason: _____________________________
Name: _______________________
Reason: _____________________________
Name: _______________________
Reason: _____________________________
Name: _______________________
Reason: _____________________________
Yes No
Are you possibly pregnant?
Surgical History:
–>
If Yes, what trimester?
Yes
Previous Surgeries?
1
2
3
No
If Yes, please start with most recent first:
1. _______________________________________________________________
Date: ___________
2. _______________________________________________________________
Date: ___________
3. _______________________________________________________________
Date: ___________
4. _______________________________________________________________
Date: ___________
5. _______________________________________________________________
Date: ___________
Trauma History:
–>
Please list Injuries with the most recent first.
Fall Auto Sport Other
1. _____________________________________
Date: ___________
Fall Auto Sport Other
2. _____________________________________
Date: ___________
Fall Auto Sport Other
3. _____________________________________
Date: ___________
Fall Auto Sport Other
4. _____________________________________
Date: ___________
Fall Auto Sport Other
5. _____________________________________
Date: ___________


Present Complaints:
* Please rate your current complaints from 1 to 10, as described on page 7.
1. _________________________________
*Intensity Rating: ____
*Frequency Rating: ____
2. _________________________________
*Intensity Rating: _____
*Frequency Rating: _____
3. _________________________________
*Intensity Rating: _____
*Frequency Rating: _____
4. _________________________________
*Intensity Rating: _____
*Frequency Rating: _____
Dr. Notes: ______________________________________________________________________________
_________________________________________________________________________________
5
Matthew J. Lieber, D.C., LLC
677 Tomlinson Lane * Yardley * PA * 19067
215-436-7227
Out of all your health problems, which one would you most want to have fixed? ________________________
When did you first notice this problem?
Approximate or Exact Date: ________________________
In what manner did this problem begin?
Suddenly
Gradually
From what did this problem develop?
Job Related Injury
Auto Collision
Home Injury
Illness
Unknown
Other ______________________
If known, describe how this problem occurred? _______________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Have you ever had this problem before?:
Yes
No
When? ____________________
Been seen by another Doctor or Therapist for this?
Yes
No
When? ____________________
If Yes, Name/Location: ___________________________________________ Phone #: __________________
Please show the areas of discomfort in the diagrams below:
Area of Complaint - Front View
Right
Side
Area of Complaint - Back View
Left
Side
Left
Side
Right
Side
Identifying Labels
P = Pain
B = Burning
N = Numbness
S = Sharp
A = Ache
T = Tension
H = Hot
C = Cold
Figure 1- Shade FRONT Areas of in region of complaint
and note the type of problem with identifying labels
Figure 2- Shade BACK Areas of in region of complaint and
note the type of problem with identifying labels
Please check all activities that AGGRAVATE/WORSEN your primary complaint:
Bending
Reaching
Straining at stool
Coughing/Sneezing
Sitting
Standing
Lifting
Turning head
Lying down/Sleeping
Walking
Other _________________________________________________________________________________
Please check all activities that RELIEVE/IMPROVE your primary complaint:
Bending
Reaching
Straining at stool
Coughing/Sneezing
Sitting
Standing
Lifting
Turning head
Lying down/Sleeping
Walking
Other _________________________________________________________________________________
(Please note: All information in this and other patient forms are kept private and confidential according to the 2003 HIPPA guidelines.)
Patient's Signature: ______________________________________ Date: _______________
6
Matthew J. Lieber, D.C., LLC
677 Tomlinson Lane * Yardley * PA * 19067
215-436-7227
How to rate the INTENSITY of your pain, 1 – 10?
10 - Your pain is intense, and considered the worst pain you have felt.
9
- Pain is intense, but not the worst pain you have felt in your life.
8
- The pain is significant and intense.
7
- Pain is significant and intense but you can bear it.
6
- The pain is moderate and significant.
5
- The pain is moderate but doesn’t get in your way throughout the day.
4
- The pain is a nuisance and annoying.
3
- Pain is mild and distracting.
2
- At its worst, the pain is best described as "a little uncomfortable".
1
- Pain is barely noticeable.
How to rate the FREQUENCY of your pain, 1 – 10?
10 - Your pain is constant both during the day and at night.
9
- Your pain is constant, but you can forget about it from moment to moment.
8
- You can forget about the pain for up to an hour at a time.
7
- Your pain can disappear for several hours at a time.
6
- Half of your day can go by without being aware of the pain.
5
- The majority of your day is spent without noticing your pain.
4
- Entire day can go by without noticing the pain.
3
- Several days can go by without being aware of it.
2
- Symptom does not recur more frequently than once a week.
1
- Symptom does not recur more frequently than once a month.
7
Matthew J. Lieber, D.C., LLC
677 Tomlinson Lane * Yardley * PA * 19067
215-436-7227