Online Forms

Online Forms

Online Forms

At Graber Chiropractic Center, we offer patient forms online so you can complete them in the convenience of your own home or office. You may email us the completed forms or bring them with you on your next visit.
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  • Download the necessary form(s), print it out and fill in the required information.

CONFIDENTIAL
HEALTH INFORMATION

Please allow our staff to photocopy your driver’s license and insurance details.
All information you supply is confidential. We comply with all federal privacy standards.

Today’s Date:

Whom may we thank for referring you?


Have you consulted a chiropractor before?


Name:

Gender:

Your Social Security No:

Birth Date:

Address:

City:

State/Province:

ZIP/Postal Code:

Marital Status:

Spouse’s Name:

Child’s Name and Age:

Child’s Name and Age:

Child’s Name and Age:

Home Phone:

Cell Phone:

Phone:

Email Address:

Emergency Contact:

Your Occupation:

Your Occupation:

Your Employer:

Address:

City:

State/Province:

ZIP/Postal Code:

May we contact you at work?

Preferred method of contact?

Work Phone

Insurance Carrier:

Policy Number:

Primary Care Provider’s Name:

Insured’s Last Name:

Birth Date:

Who carries this policy?

First Name:

Middle Name (or Initial):

Insured’s Employer:

Address:

City:

State/Province:

ZIP/Postal Code:

Employer’s Phone:

1. The symptom(s) that have prompted me to seek care today include:

2. And are the result of (darken circle):

An accident or injury:

A worsening long-term problem:

An interest in:

3. Onset (When did you first notice your current symptoms?)

4. Intensity (How extreme are your current symptoms?)

5. Duration and Timing (When did it start and how often do you feel it?)

6. Quality of symptoms (What does it feel like?)

7. Radiation (Does it affect other areas of your body? To what areas does the pain radiate, shoot or travel.)

8. Aggravating or relieving factors (What makes it better or worse, such as time of day, movements, certain activities, etc.)

9. Prior interventions (What have you done to relieve the symptoms?)

10. What else should Graber Chiropractic Center know about your current condition?

11. How does your current condition interfere with your:​​​​​​​

12. Review of Systems

Chiropractic care focuses on the integrity of your nervous system, which controls and regulates your entire body. Please darken the circle beside any condition that you’ve Had or currently Have and initial to the right.

a. Musculoskeletal

Osteoporosis

Knee injuries

Arthritis

Foot/ankle pain

Scoliosis

Shoulder problems

Neck pain

Elbow/wrist pain

Back problems

TMJ issues

Hip disorders

Poor posture

b. Neurological

Anxiety

Depression

Headache

Dizziness

Pin and Needles

Numbness

c. Cardiovascular​​​​​​​

High blood pressure

Low blood pressure

High cholesterol

Poor circulation

Angina

Excessive bruising

d. Respiratory​​​​​​​

Asthma

Apnea

Emphysema

Hay fever

Shortness of breath

Pneumonia

e. Digestive​​​​​​​

Anorexia/bulimia

Ulcer

Food sensitivities

Heartburn

Constipation

Diarrhea

f. Sensory

Blurred vision

Ringing in ears

Hearing loss

Chronic ear infection

Loss of smell

Loss of taste

g. Skin​​​​​​​

Skin cancer

Psoriasis

Eczema

Acne

Hair loss

Rash

h. Endocrine

Thyroid issues

Immune disorders

Hypoglycemia

Frequent Infection

Swollen glands

Low Energy

i. Genitourinary​​​​​​​

Kidney stones

Infertility

Bedwetting

Prostate issues

Erectile dysfunction

PMS symptoms

j. Constitutional

Fainting

Low libido

Poor appetite

Fatigue

Sudden weight gain/loss

Weakness

PERSONAL

13. Illnesses
Check the illnesses you have Had in the past or Have now

AIDS

Alcoholism

Allergies

Arteriosclerosis

Cancer

Chicken pox

Diabetes

Epilepsy

Glaucoma

Goiter

Gout

Heart disease

Hepatitis

HIV Positive

Malaria

Measles

Multiple Sclerosis

Mumps

Polio

Rheumatic fever

Scarlet fever

Sexually transmitted disease

Stroke

Tuberculosis

Typhoid fever

Ulcer

14. Operations
Surgical interventions, which may or may not have included hospitalization.

15. Treatments
Check the ones you’ve received in the Past or are receiving Currently.

Acupuncture

Antibiotics

Birth control pills

Blood transfusions

Chemotherapy

Chiropractic care

Dialysis

Herbs

Homeopathy

Hormone replacement

Inhaler

Massage therapy

Physical therapy

Nutritional supplements:

Medications (prescription and over-the-counter):

16. Injury
Have you ever...

FAMILY

17. Family History
Some health issues are hereditary. Tell Graber Chiropractic Center about the health of your immediate family members.

Mother

Age (If living)

State of health

Illnesses

Age at death

Cause of Death


Father

Age (If living)

State of health

Illnesses

Age at death

Cause of Death


Sister 1

Age (If living)

State of health

Illnesses

Age at death

Cause of Death


Sister 2

Age (If living)

State of health

Illnesses

Age at death

Cause of Death


Brother 1

Age (If living)

State of health

Illnesses

Age at death

Cause of Death


Brother 2

Age (If living)

State of health

Illnesses

Age at death

Cause of Death

18. Are there any other hereditary health issues that you know about?

20. Social History
Tell Graber Chiropractic Center about your health habits and stress levels.

Alcohol use

Coffee use

Tobacco use

Exercising

Pain relievers

Soft drinks

Water intake

Prayer or meditation?

Job pressure/stress?

Financial peace?

Vaccinated?

Mercury fillings?

Recreational drugs?

20. Activities of Daily Living
How does this condition currently interfere with your life and ability to function?

Sitting

Rising out of chair

Standing

Walking

Lying down

Bending over

Climbing stairs

Using a computer

Getting in/out of car

Driving a car

Looking over shoulder

Caring for family

Grocery shopping

Household chores

Lifting objects

Reaching overhead

Showering or bathing

Dressing myself

Love life

Getting to sleep

Staying asleep

Concentrating

Exercising

Yard work

21. What is the major stressor in your life?

22. How much sleep do you average per night?

23. What is the type and approximate age of your mattress and pillow?​​​​​​​

24. What is your preferred sleeping position?​​​​​​​

25. Describe your typical eating habits:​​​​​​​

26. What would be the most significant thing that you could do to improve your health?​​​​​​​

27. In addition to the main reason for your visit today, what additional health goals do you have?

Acknowledgements

To set clear expectations, improve communications, and help you get the best results in the shortest amount of time, please read each statement and initial your agreement.

If the patient is a minor child, print child’s full name:

Signature

Date:

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