City chiropractic registration and history, dated _____________________________

Name ___________________________________________ Are you here to address a specific problem?_______________________________________________ Birth date: _______________________ Age: __________ _______________________________________________ Cel Phone: _____________________________________ Is the condition worsening? YES NO UNKNOWN Home Phone: ___________________________________ Address:________________________________________ ____________________________, _____ ____________ Email: _________________________________________ Employer name __________________________________ How often? _____________________________________ Employment type: _______________________________ Seeking treatment due to a work accident? Whom may we thank for referring you? _________________ How often/Type____________________________________Likes ____________________________________________ What are you hoping to get out of your massage today? _______________________________________________ Mark an X on the picture where you'd like work addressed Injuries/Surgeries you’ve had. These are important and may shed light on current postural issues, even if you don't think they were that bad at the time. Please include fender benders and the like, and injuries in childhood.
Description Date MVA's ___________________________________________________________________ _____________ Sprains/Strains ___________________________________________________________________ _____________ Head Injury ___________________________________________________________________ _____________ Broken Bones ___________________________________________________________________ _____________ Dislocations ___________________________________________________________________ _____________ Surgeries ___________________________________________________________________ _____________ Other ___________________________________________________________________ _____________ Do you have, or have you had in the past, any of the fol owing diseases (please circle): Cancer, Heart disease, High Blood Pressure, Skin Conditions/Rashes, Diabetes, HIV/AIDS,
Herpes, Headaches, Migraines, Kidney/Liver Disease, IBS, Celiac, Seasonal Allergies, Psychiatric
conditions.
Other/Details (Date of Onset, Frequency, Diagnosis, Tx/Rx). Please also list any conditions which are chronic or recurring, such as frequent infections or other dysfunction: ____________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Are you currently on any medications, including over the counter pain kil ers or cold medicine? ________________________ Any family History of significant disease?__________________________________________________________________ Are you Pregnant? YES NO UNKNOWN Congrats! When is your due date?______________________ How do you tend to eat? (A huge meal a day/Lots of small meals) ___________________________________________________ Favorite foods? _____________________________________________________________________________________ When you crave junk, do you go for sweets, or salt/fat? ______________________________________________________ Height _____________ Weight ________________ Al ergies ___________________________________________ Vitamins/Supplements ________________________________________________________________________________ Do you fal asleep easily?______________________________ Stay asleep through the night? _______________________ How many hours of sleep on average? _________________ Do you wake feeling rested? ___________________________ How's your water intake? __________________________________________ Do you carry a bottle? _______________ ________________________________________________ ________________________________________________

Source: http://artfultouch.info/new-pt-documents/ARTFUL%20TOUCH%20REGISTRATION%20AND%20HISTORY.pdf