Vitality Spine & Rehab

Patient Data

    Confidential Patient Information

    Mr.Mrs.Ms.MissDr.Other


















    MaleFemale
    SingleMarriedDivorcedWidowed




    YesNo

    Motor Vehicle AccidentWork InjuryOther Injury
    Your Health Profile

    Why this form is important- As a family wellness oriented chiropractic office, we focus on helping you maximally express your health potential. Our first goal is to locate and eliminate any and all interference to the full outward expression of that potential and address the issues that brought you here. In addition, we hope to offer you and your family the opportunity for a lifetime of health, happiness and vitality. On a daily basis we all experience physical, chemical and emotional stresses that can accumulate and result in serious loss of health potential. Most times, the affects are so gradual that they are not felt until they become serious, and sometimes not until it’s too late! Your answers to the following questions will give us a general view of the stresses you have face in your lifetime, thus allowing us to better assess your current status and more accurately determine your true health potential.
    The Beginning Years- Research is showing that many of the health challenges that occur later in life have their origins during developmental year, some even starting at birth. Please answer the following questions to the best of your ability.


    Mother smokes/drank/drugs during pregnancyEpidura/Meds in LaborBreech Vaginal DeliveryC-SectionForceps DeliveryVacuum Extractor usedLabor InducedComplicationsOthers


    Childhood IllnessesSerious FallsActive in SportsVery InactiveCar Accident(s)Surgery/StitchesAlcohol/Drug AbuseSmokerAntibiotics/Other MedsVaccinatedUnder Chiropracter CareBroken BonesSevere Emotional Trauma(s)


    Present SmokerFormer SmokerOTC/Prescription MedsAlcohol UseSurgery/StitchesPlay SportsCar AccidentsWork InjuryHigh Job StressHigh Personal StressSit a lotDrive a lotPoor SleepNot Enough SleepPoor/Inadequate DietNo ExerciseFlat FeetWear Orthodics/LiftsSevere Health ProblemsHard FallsBroken BonesOther Injuries



    Addressing the issues that brought you to our office


    SharpDullConstantIntermittentTravelingRadiatingMildModerateModerately SevereSevereIntolerable


    About The SameGetting BetterGetting WorseVariable



    WorkSleepWalkingSittingExerciseHobbiesLeisure Activities


    YesNo


    YesNo

    Chiropractor
    Medical Doctor
    Other



    Headaches/MigrainesPins & Needle in Legs/FeetRecurring InfectionInfertility/Impotence/MiscarriagePins & Needle in ArmsLoss of SmellDizziness/VertigoBuzzing/Ringing in EarsSinus Problems/AllergiesNervousness/AnxietyNumbness in FingersNumbness in ToesLoss of TasteUpset StomachFatigueDepressionIrritability/Mood SwingsNeck Stiffness/PainCold HandsCold FeetDiarrhea/Constipation/GasFoot ProblemsShortness of BreathHot FlushesCold SweatsLight Bothers EyesProblem UrinatingHeartburn/RefluxMenopausePre-Menstrual SyndromeUlcersOther

    Family Health Profile- in our office, we are not only interested in your health and well being but also in that of your family and loved ones. Please mention below any health conditions or concerns you may have about your: