CLIENT INFORMATIONClient Name First Middle Last Employer/School Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneOccupation Cell PhoneSpouse's Name Email Address Spouse's Employer Gender M F Status Married Widowed Separated Divorced Single Partnered Minor AgeBirthday MM slash DD slash YYYY IN CASE OF EMERGENCY, CONTACTName Relationship Contact Number Who may we thank for referring you? Have you ever experience chiropractic before? Yes No HOW CAN WE HELP YOU?What brings you here today?If you are experiencing a symptom, what is it? How bad is it? How intense are your symptoms? 0 - No Symptoms 1 2 3 4 5 6 7 8 9 10 - Intense Symptoms Please state which part of your body you feel pain / symptoms. What does it feels like? Numbness TIngling Stiffness Dull Aching Cramping Nagging Sharp Shooting Burning Throbbing Stabbing Swelling Others IMPACT OF YOUR SYMPTOMSHow is this symptom/condition interfering with your life? (check where appropriate)Work No Effect Mild Effect Moderate Effect Severe Effect Energy No Effect Mild Effect Moderate Effect Severe Effect Exercise No Effect Mild Effect Moderate Effect Severe Effect Attitude No Effect Mild Effect Moderate Effect Severe Effect Recreation No Effect Mild Effect Moderate Effect Severe Effect Patience No Effect Mild Effect Moderate Effect Severe Effect Relationships No Effect Mild Effect Moderate Effect Severe Effect Productivity No Effect Mild Effect Moderate Effect Severe Effect Sleep No Effect Mild Effect Moderate Effect Severe Effect Creativity No Effect Mild Effect Moderate Effect Severe Effect Self-Care No Effect Mild Effect Moderate Effect Severe Effect Other No Effect Mild Effect Moderate Effect Severe Effect How committed are you in correcting this issue? 0 - Not Committed 1 2 3 4 5 6 7 8 9 10 - Very Committed CLIENT WELLNESS ASSESSMENT Carefully considering the arrow diagram above, what number do you think represents your health status today? In complete honesty, in what direction do you believe your current health status is headed? What number do you think represents your health today? In what directions is your health currently headed? What are your health goals and how long to achieve?Immediate Health GoalsShort Term Health GoalsLong Term Health Goals CHILDREN & PREGNANCYHow many children do you have? Are you currently pregnant? Yes No I'm due Children's ages? Number of past pregnancies? Children's health concerns? Health concerns regarding this pregnancy? HEALTH & ILLNESS HISTORYPlease check the box beside any condition that you have or have had. AIDS/HIV Circulation Issues Headaches/Migraines Reproductive Issues Alcoholism Childhood Illness Heart Disease Ringing in Ears Anxiety Depression Hepatitis Scoliosis Arteriosclerosis Diabetes Hip Issues Shoulder Issues Arthritis Digestive Issues Immune Issues Sleep Issues Asthma/Allergies Elbow/Wrist/Hand Issues Lymphatic Issues Stroke Back Pain Endocrine Issues (Thyroid) Multiple Sclerosis TMJ Issues Cardiovascular Issues Foot/Ankle Issues Neck Pain Urinary Issues Cancer Gout Osteoporosis Performance Issues Others Any significant Emotional Traumas or Stresses since birth? ALLERGIES, MEDICATIONS & SUPPLEMENTSALLERGIES (list)MEDICATIONS (list)SUPPLEMENTS (list)
