Online Forms Here

Parkhurst Chiropractic & Lakeshore Wellness Center
New Patient Health History Form
In order to provide you the best possible wellness care, please complete this form
and bring it to your first appointment. All information is strictly CONFIDENTIAL.
Patient Data
Name ___________________________________ Date ________ Email _______________________________________
Your email will NOT be shared with any 3d parties, and is used
for occasional office announcements and promotions.
Address ________________________________________ City _______________ State ________________ Zip _______
Telephone – Please check preferred method of contact
(work) _____________________ (home) ______________________________(cell)_________________________
Age _________Birth date _____________________Marital Status _________________
Occupation ______________________Employer________________________________________________
Emergency contact __________________________________Phone ____________________________
Demographics*
*Information required by Affordable Care Act
Height:__________
Weight:______________
Tobacco Use?  No  Yes  Former
High Blood Pressure?  No  Yes _________________________
Alcohol Use?  Never  Occasionally  Socially  Frequently (more than 3 days per week)
Patient Race:  Asian  Black/African American  Caucasian/White  Latin American
 Native American  Pacific Islander  Other _____________________________________
Language:__________________________________________________
List your top 3 Current Complaints
Check all that apply
1._____________________________________________________
_______________________________________________________
2._____________________________________________________
_______________________________________________________
3._____________________________________________________
_______________________________________________________
Headaches
Neck Pain
Upper Back Pain
Lower Back Pain
Hip
Arm
Leg
Yes







How did your symptoms begin?
 Automobile  Work  Accident  Trauma  Illness  Aggravation of Congenital Problem,
Onset started as follows: ___________________________________________________________________________
What best describes your symptoms? (check all that apply)
 throbbing  shooting  torturing  sharp  burning  numbing  nagging  cramping  constant
 dull  aching  intermittent  radiating  hypersensitive
Comments________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
What worsens your pain or symptoms? (check all that apply)
 standing  bending  emotional stress  sleeping  walking  sexual activity  menstruating

sitting  touching affected area  moving from a sitting to standing position
 Other ___________________________________________________________________________________________
Has your problem decreased or prevented your ability to exercise:  Yes  No
Parkhurst Chiropractic & Lakeshore Wellness Center
Medical History
Primary Care Physician _____________________________________________________________________
Date of last physical exam ____________________________ Is there a chance that you are pregnant?  No  Yes
What Prescription Medications or Supplements are you taking (Please list dosage and amounts, etc).
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
What drug allergies are you aware of?
___________________________________________________________________________________________________________
Check all past and present medical health
problems (please select all that apply)
I am in Good Health
Diabetes
Lung Disease
Stomach problems
Ulcer Disease
Kidney Disease
Mitral Valve Prolapse
High Cholesterol
Heart Problems
Liver Problems
Asthma
Bleed Easily
Arthritis
Indicate all past surgeries
No History of Surgical Procedures
Please list all past surgeries
Yes
Briefly Explain













Yes
Briefly Explain




Family History – Indicate if your parents, sisters or
brothers had any of these conditions.
No family history of problems
Arthritis
High Blood Pressure
High Cholesterol
Diabetes
Heart Disease
Cancer
Chronic Pain
Yes










Briefly Explain
Parkhurst Chiropractic & Lakeshore Wellness Center
Review of Systems
If you have an issue in a section below, check your issue.
If you have no problems relating to that question, check the “No Problems” box.
Do any of the following
apply?
No Problems
Fatigue
Night Sweats
Weight Issues
Loss of Energy
Do you have any endocrine
problems?
No Problems
Diabetes
Thyroid Disorder
Yes






Yes



Do any of the following
apply?
No Problems
Irritability
Depression
Disturbed Sleep
Anxiety
Nervousness
Do you have any
neurological problems
No Problems
Seizures
Loss of Memory
Yes






Yes



Do you have any of the issues below? If yes, please explain.
Do you have any trouble urinating?  No  Yes If yes, explain
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Do you have trouble with your vision?  No  Yes If yes, explain __________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Do you have any symptoms of heart trouble?  No  Yes If yes, explain __________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Do you have any breathing problems?  No  Yes If yes, explain ________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Do you have any stomach problems?  No  Yes If yes, explain __________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Do you have muscle or joint pain?  No  Yes If yes, explain ____________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Do you have any allergy/immunity problems?  No  Yes If yes, explain __________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Do you have bruising or bleeding problems?  No  Yes If yes, explain ___________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________