LIST YOUR HEALTH CONCERNS BELOW

Health concerns According to severity
Severity on Scale of 1-10
When did episode begin?
If you had the condition before, when?
Did the problem begin with an injury?
Are symptoms constant or intermittent

ALL SURGICAL OPERATIONS AND YEARS:

LIST ALL OVER THE COUNTER & PRESCRIPTION MEDICATIONS YOU ARE ON

WHEN WAS YOUR LAST AUTO ACCIDENT?

HAVE YOU HAD PREVIOUS CHIROPRACTIC CARE?

IF YOU HAVE, WHO DID YOU SEE AND WHEN?

HAVE YOU EVER BEEN KNOCKED UNCONSCIOUS?

FRACTURED A BONE?

IF YES, PLEASE DESCRIBE

OTHER TRAUMA?

DO YOU VIEW YOUR HEALTH AS AN INVESTMENT OR EXPENSE?

HOW COMMITTED ARE YOU TO LIVING A HEALTHIER LIFE ON A SCALE OF 1-10 WITH 10 BEING THE HEALTHIEST LIFE POSSIBLE?

HOW WOULD YOUR LIFE CHANGE IF YOU DIDN'T HAVE THE HEALTH CONDITIONS YOU INDICATED ON THIS FORM?

WRITTEN CONSENT FOR A MINOR CHILD

NAME OF PRACTICE MEMBER WHO IS A MINOR CHILD

I Authorize Dr. Athena Payne, D.C. to perform diagnostic procedures, render chiropractic care and perform chiropractic adjustments to my minor child.

AS OF THIS DATE, I HAVE THE LEGAL RIGHT TO SELECT AND AUTHORIZE HEALTH CARE SERVICES FOR MY MINOR CHILD. IF MY AUTHORITY TO SELECT AND AUTHORIZE IS REVOKED OR ALTERED, I WILL IMMEDIATELY NOTIFY

GUARDIAN SIGNATURE

Clear

GUARDIAN'S RELATION TO MINOR CHILD

Witness

Date of Written Consent

Please Share The Following:

1. How Often Do You Exercise?

1(a). How Long?

2. What Type Of Exercise Do Your Perform?

3. Please Share A Typical Day of Eating For You Including Times and Quantity:

Breakfast
Lunch
Dinner
Dinner

4. What Time Do You Usually Eat Last?

5. What Time Do You Typically Go To Bed?

6. How many ounces of water do you drink a day?

6(a). Source?

7. How many cups of coffee do you drink a day?

8. What do you put in your coffee?

9. How many alcoholic beverages do you consume?

(9) How many alcoholic beverages do you consume?

a. Each day?
b. Week?
c. Month?

10. What else do you drink daily?

11. Do you smoke cigarettes?

(11)a. How many packs a day?

(11)b. Week?

12. Do you consume any type of drugs?

12(a). If yes what and how often

13. Do you meditate?

13(a). If so how often and for how long?

14. What type of music do you listen to?

14(a). How many minutes per day?

15. Do you engage in any type of personal development programs?

16. If so please explain the type, frequency, and duration?

17. Do you or have you ever seen a counselor?

18. On a scale of 1-10 rate your stress levels:

Your Full Name

Date For Family Health History

Please Complete this Form In its Entirety