FIELDS CHIROPRACTIC CLINIC
Date: _____________________________
Patient Name  ___________________________________      Cell Phone: ___________ Cell Phone Carrier  ______________
Address ___________________________________________City  ______________State ____________  Zip ___________
Email Address ___________________________________  Race ___________________  Ethnicity ____________________
(i.e. Asian, Hispanic, White, etc. )                  (i.e. Latin, German, Korean, etc.)
Date of Birth ___________    Age _____      Gender ___M  ___ F         Marital Status ________        # of Children _________
Primary Care Physician's Name, Address and Phone/Fax Number  _________________________________________
_____________________________________________________________________________________________________
Referred to our office by : ________________________________________________________________________________
Emergency Contact Name _________________________Phone  Number _________________Relationship ______________
Please check all of the following that apply to you :
_____ Alcohol Use
_____ Prostate Problems
_____ Drug Use (Non-Prescription)
_____ Tobacco Use   If so, Type __________________
_____ Diabetes
_____ Menstrual Problems
_____Urinary Problems
_____ Currently Pregnant, # Weeks _______
_____ Abnormal Weight ___Gain   ___Loss
_____ Marked Morning Pain/Stiffness
_____ Pain Unrelieved by Position or Rest
_____ Pain at Night
_____ High Blood Pressure
_____ Stroke (Date) ________________
_____ Corticosteriod Use (Cortisone,Prednisone, etc.)
_____ Taking Birth Control Pills
_____ Dizziness/Fainting
_____ Visual Disturbances,  If so, explain _______
___________________________________________
_____ Osteoporosis
_____ Numbness in Groin/Buttocks
_____ Cancer/Tumor (Explain) ________________
_________________________________________
_____ Epilepsy/Seizures
Surgeries [ list date(s) and procedure(s) ] ___________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Other Health Problems (i.e. allergies, etc.) __________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Medications (Name of drug and indicate condition being treated, or attach a copy of  list)_____________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Family History
____ High Cholesterol ( Mother )
____ High Cholesterol ( Father )
____ Diabetes ( Mother )
____ Heart Problems ( Mother )  Specify Condition __________
____ Heart Problems ( Father )  Specify Condition ___________
____ Stroke ( Mother )
____ Diabetes ( Father )
____ Stroke ( Father )
____ High Blood Pressure ( Mother )
____ High Blood Pressure ( Father )
____ Osteoarthritis ( Mother )
____ Osteoarthritis ( Father )
____ Rheumatoid Arthritis ( Mother )
____ Rheumatoid Arthritis ( Father )
____ Cancer ( Mother )  Specify Condition __________________
____ Cancer ( Father )  Specify Condition ___________________
4700 FM 2920 Rd., #1, Spring Tx., 77388,  Phone 281-353-3544,   Fax 281-288-5566

 
1ST AREA OF CONCERN:
DESCRIBE YOUR CURRENT PROBLEM:  ________________________________________________________________.
Is this?  _____Work Related   ___ Auto Related  ___ N/A
HOW PROBLEM BEGAN: ______________________________________________________________________________
HOW DO YOU FEEL TODAY ?           (Circle one)      NO PAIN    1   2   3   4   5   6   7   8   9   10   UNBEARABLE  PAIN.
DATE PROBLEM BEGAN ______________________
HOW OFTEN ARE YOUR SYMPTOMS PRESENT?(Circle one)  Occasional  __0-25% __26-50% __51-75% ___76-100%
In the past week, how much has your pain interfered with your daily activities  ( i.e., work, social activities, or
household chores)?         (Circle one)   No interference  1  2   3  4  5  6  7  8  9  10  Unable to carry on any activities.
Have you had x-rays, MRIs, or CT scans for this area of concern?  ___Yes   ___No     Date taken: __________________
2ND AREA OF CONCERN:
DESCRIBE YOUR CURRENT PROBLEM:_________________________________________________________________.
Is this?  _____Work Related   ___ Auto Related  ___ N/A
HOW PROBLEM BEGAN: ______________________________________________________________________________
HOW DO YOU FEEL TODAY ?           (Circle one)      NO PAIN    1   2   3   4   5   6   7   8   9   10   UNBEARABLE  PAIN.
DATE PROBLEM BEGAN ______________________
HOW OFTEN ARE YOUR SYMPTOMS PRESENT? (Circle one)  Occasional  __0-25% __26-50% __51-75% __76-100%
In the past week, how much has your pain interfered with your daily activities  ( i.e., work, social activities, or
household chores)?         (Circle one)   No interference  1  2   3  4  5  6  7  8  9  10  Unable to carry on any activities.
Have you had x-rays, MRIs, or CT scans for this area of concern?  ___Yes   ___No     Date taken: __________________
3RD AREA OF CONCERN:
DESCRIBE YOUR CURRENT PROBLEM:  ________________________________________________________________.
Is this?  _____Work Related   ___ Auto Related  ___ N/A
HOW PROBLEM BEGAN: ______________________________________________________________________________
HOW DO YOU FEEL TODAY ?           (Circle one)      NO PAIN    1   2   3   4   5   6   7   8   9   10   UNBEARABLE  PAIN.
DATE PROBLEM BEGAN ______________________
HOW OFTEN ARE YOUR SYMPTOMS PRESENT? (Circle one)  Occasional  __0-25% __26-50% __51-75% __76-100%
In the past week, how much has your pain interfered with your daily activities  ( i.e., work, social activities, or
household chores)?         (Circle one)   No interference  1  2   3  4  5  6  7  8  9  10  Unable to carry on any activities.
Have you had x-rays, MRIs, or CT scans for this area of concern?  ___Yes   ___No     Date taken: __________________
MARK AN "X" ON THE DIAGRAM WHERE YOU HAVE PAIN OR OTHER SYMPTOMS. PLEASE  INDICATE
NEXT TO "X" IF PAIN IS DULL ACHE, BURNING, NUMB/TINGLING, SHARP, STABBING, TIGHTNESS OR
THROBBING.