Name:*

Preferred name:

Address:*

City:*

State:*

Zip:*

Home phone number:

Work phone number:

Cell phone number:

E-mail:*

Male/Female:*

Birth date:*

Age:*

Your occupation:*

Emergency contact:*

Relationship:*

Phone number:*

Whom may we thank for referring you to us?

Marital Status:*

Name of insurance company:*

Contract number: *

Group number: *

Is your insurance policy under your name?*

If not, whose name is it under?

What is your relationship to this person?

Birth date of insured:

Phone number of insurance company (on back of card):*

Address of the insurance company (on back of card):*

Name of insurance company:

Contract number:

Group number:

Is your insurance policy under your name?

If not, whose name is it under?

What is your relationship to this person?

Birth date of insured:

Phone number of insurance company (on back of card):

Address of the insurance company (on back of card):

Is this your first chiropractic experience? Yes No

If no, please describe your past care:

Is this your first clinical nutrition experience? Yes No

If no, please describe your past care:

List your previously diagnosed health issue/s.
For example: diabetes, high blood pressure, IBS, etc…

Health Issue 1:  

Health Issue 2:  

Health Issue 3:  

Health Issue 4:  

Health Issue 5:  

List your surgeries.

1.  

2.  

3.  

4.  

5.  

List any supplement/s, vitamin/s, herb/s, homeopathic/s, medication/s you are taking and the reason for which you are taking them:

1.  

      Reason:  

2.  

      Reason:  

3.  

      Reason:  

4.  

      Reason:  

5.  

      Reason:  

When did this start?*

How did this start? Was there a specific event?*

Was it a sudden or gradual onset?*

How does it feel?*

If there is pain, does it stay in one place or does it travel?*

If it travels where does it travel to?*

What makes it feel better?*

What makes it feel worse?*

What time of the day is it better?*

What time of the day is it worse?*

What do you think is the cause of this?*

What other test/s, procedure/s have you had in regards to this issue?*

What have been the results of this/these procedure/s?*

Is there anything about this issue that is limiting you in your daily activity?
If yes, what is it?

Is there anything else you would like to mention regarding this issue?

When did this start?

How did this start? Was there a specific event?

Was it a sudden or gradual onset?

How does it feel?

If there is pain, does it stay in one place or does it travel?

If it travels where does it travel to?

What makes it feel better?

What makes it feel worse?

What time of the day is it better?

What time of the day is it worse?

What do you think is the cause of this?

What other test/s, procedure/s have you had in regards to this issue?

What have been the results of this/these procedure/s?

Is there anything about this issue that is limiting you in your daily activity?
If yes, what is it?

Is there anything else you would like to mention regarding this issue?

When did this start?

How did this start? Was there a specific event?

Was it a sudden or gradual onset?

How does it feel?

If there is pain, does it stay in one place or does it travel?

If it travels where does it travel to?

What makes it feel better?

What makes it feel worse?

What time of the day is it better?

What time of the day is it worse?

What do you think is the cause of this?

What other test/s, procedure/s have you had in regards to this issue?

What have been the results of this/these procedure/s?

Is there anything about this issue that is limiting you in your daily activity?
If yes, what is it?

Is there anything else you would like to mention regarding this issue?

What is it you are unable to do now that you normally are able to???
(i.e.: bend over to put on your shoes, unload the the dishwasher, etc...)

Difficulty getting up in the morning.

0 1 2 3 4 5

Continued fatigue that is not relieved by sleep and rest.

0 1 2 3 4 5

Lethargy; lack of energy to do normal activities.

0 1 2 3 4 5

Sugar cravings.

0 1 2 3 4 5

Salt cravings.

0 1 2 3 4 5

Allergies.

0 1 2 3 4 5

Digestion problems.

0 1 2 3 4 5

Increased effort needed for everyday tasks.

0 1 2 3 4 5

Decreased interest in sex.

0 1 2 3 4 5

Decreased ability to handle stress.

0 1 2 3 4 5

Increased time needed to recover from illness, injury or trauma.

0 1 2 3 4 5

Light-headed or dizzy when standing up quickly.

0 1 2 3 4 5

Depressed.

0 1 2 3 4 5

Less enjoyment or happiness with life.

0 1 2 3 4 5

Increased PMS.

0 1 2 3 4 5

Symptoms are worse if meals are skipped or inadequate.

0 1 2 3 4 5

Thoughts are less focused; brain fog.

0 1 2 3 4 5

Memory is poor.

0 1 2 3 4 5

Decreased tolerance for stress, noise, disorder.

0 1 2 3 4 5

Don’t really wake up until after 10:00 AM.

0 1 2 3 4 5

Afternoon low between 3:00 PM–4:00 PM.

0 1 2 3 4 5

Feel better after supper.

0 1 2 3 4 5

Get a “second wind” in the late evening, and stay up late.   

0 1 2 3 4 5

Decreased ability to get things done—less productive.  

0 1 2 3 4 5

Have to keep moving—if I stop I will get tired.   

0 1 2 3 4 5

Feeling overwhelmed by all that needs to be done.   

0 1 2 3 4 5

It takes all my energy to do what I have to do. There’s none left over for anything or anyone else.   

0 1 2 3 4 5

Total:
A score of 20-40 suggests mild adrenal stress.
A score of 40-70 suggests moderate adrenal fatigue.
A score of 70+ suggests significant adrenal fatigue.

Fatigue.

0 1 2 3 4 5

Muscle aches and pains.

0 1 2 3 4 5

Joint pain.

0 1 2 3 4 5

Fibromyalgia.

0 1 2 3 4 5

Feelings of weakness.

0 1 2 3 4 5

Lethargy, or loss of interest in daily activities.

0 1 2 3 4 5

Memory loss.

0 1 2 3 4 5

Difficulty in concentrating.

0 1 2 3 4 5

Mental sluggishness.

0 1 2 3 4 5

Low moods.

0 1 2 3 4 5

Depression.

0 1 2 3 4 5

Cold hands and feet.

0 1 2 3 4 5

Feel cold a lot.

0 1 2 3 4 5

Tendency towards constipation.

0 1 2 3 4 5

Weight gain.

0 1 2 3 4 5

Sweet and carbohydrate cravings.

0 1 2 3 4 5

Low blood sugar/Hypoglycemia.

0 1 2 3 4 5

Menstrual problems.

0 1 2 3 4 5

Heavy bleeding during menses.

0 1 2 3 4 5

Repeated colds and flu.

0 1 2 3 4 5

Skin problems (itching, eczema, psoriasis, acne, or coarse, dry, scaly skin).

0 1 2 3 4 5

Low or high blood pressure.

0 1 2 3 4 5

Do not perspire easily .   

0 1 2 3 4 5

Hoarse voice.  

0 1 2 3 4 5

Feeling of fullness in the neck area.   

0 1 2 3 4 5

Swelling of eyelids/puffy around the eyes.   

0 1 2 3 4 5

Edema.   

0 1 2 3 4 5

Can see teeth indentations around edge of my tongue (enlarged tongue) .   

0 1 2 3 4 5

Hair loss.   

0 1 2 3 4 5

Dry, coarse hair.   

0 1 2 3 4 5

Loss of outer 1/3 of eyebrows.   

0 1 2 3 4 5

I have about as many mental/emotional symptoms as physical symptoms.   

0 1 2 3 4 5

Total:
20-30 suggests a mild thyroid imbalance
40-70 suggests a moderate thyroid imbalance
70+ suggests a severe thyroid imbalance

Trouble falling asleep

     Additional Information:

Trouble staying asleep

     Additional Information:

Wake up feeling tired

     Additional Information:

Other

     Additional Information:

Constant hunger

     Additional Information:

Caffeine cravings

     Additional Information:

Carbohydrate cravings

     Additional Information:

Sugar cravings

     Additional Information:

Salt cravings

     Additional Information:

Other

     Additional Information:

Mood swings

     Additional Information:

Irritability

     Additional Information:

Depression

     Additional Information:

Low mood

     Additional Information:

Lowered self-esteem

     Additional Information:

Sadness

     Additional Information:

Crying

     Additional Information:

Foggy Thinking

     Additional Information:

Memory difficulties

     Additional Information:

Aggression

     Additional Information:

Anger

     Additional Information:

Anxiety

     Additional Information:

Panic

     Additional Information:

Emotional

     Additional Information:

Fatigue

     Additional Information:

Nervousness

     Additional Information:

Pessimism

     Additional Information:

Decreased initiative

     Additional Information:

Decreased motivation

     Additional Information:

Decreased drive

     Additional Information:

Decreased concentration

     Additional Information:

Disinterested in activities

     Additional Information:

Disinterested in relationships

     Additional Information:

Other

     Additional Information:

Weight gain

     Additional Information:

Weight loss

     Additional Information:

Decreased libido

     Additional Information:

Increased libido

     Additional Information:

Insulin resistent

     Additional Information:

Diabetic

     Additional Information:

Other

     Additional Information:

Acne

     Additional Information:

Hives, rashes, or dry skin

     Additional Information:

Hair loss

     Additional Information:

Flushing

     Additional Information:

Excessive sweating

     Additional Information:

Excessive facial hair

     Additional Information:

Other

     Additional Information:

Allergies

     Additional Information:

Asthma

     Additional Information:

Hay fever

     Additional Information:

Other

     Additional Information:

Congestion

     Additional Information:

Asthma, bronchitis

     Additional Information:

Shortness of breath

     Additional Information:

Difficulty breathing

     Additional Information:

Other

     Additional Information:

High Blood Pressure

     Additional Information:

Low Blood Pressure

     Additional Information:

High Cholesterol

     Additional Information:

Low Cholesterol

     Additional Information:

Chest Pain

     Additional Information:

Other

     Additional Information:

Headaches

     Additional Information:

Migraines

     Additional Information:

Fibromyalgia

     Additional Information:

Muscle soreness

     Additional Information:

Muscle weakness

     Additional Information:

Muscle tired

     Additional Information:

Body Aches/Stiffness

     Additional Information:

Joint Aches/Stiffness

     Additional Information:

Back Aches/Stiffness

     Additional Information:

Arthritis

     Additional Information:

Decreased Bone Density

     Additional Information:

Osteoporosis

     Additional Information:

Osteopenia

     Additional Information:

Other

     Additional Information:

Bloating

     Additional Information:

Irritable Bowel

     Additional Information:

Diarrhea

     Additional Information:

Constipation

     Additional Information:

Nausea

     Additional Information:

Vomiting

     Additional Information:

Leaky Gut

     Additional Information:

Acid Reflux

     Additional Information:

Ulcers

     Additional Information:

Celiac Disease

     Additional Information:

Belching

     Additional Information:

Gas

     Additional Information:

Heart Burn

     Additional Information:

Other

     Additional Information:

Frequent need to urinate

     Additional Information:

Urination is delayed/strained/incomplete

     Additional Information:

Pain with urination

     Additional Information:

Blood in the urine

     Additional Information:

Swollen ankles

     Additional Information:

Swollen legs

     Additional Information:

Other

     Additional Information:

Other

Are you presently using birth control? Yes
   (If no, please skip the next two questions.)

If yes, which one?

For how long have you been using it?

Have you used birth control in the past? Yes
   (If no, please skip the next two questions.)

If yes, which one?

For how long did you use it?

Hot flashes? Yes
   (If no, please skip the next five questions.)

If yes, how long has this been going on?   

What have you done for this in the past?

Did it help? Yes

What are you presently doing for this?

Is it helping? Yes

Night Sweats? Yes
   (If no, please skip the next five questions.)

If yes, how long has this been going on?   

What have you done for this in the past?

Did it help? Yes

What are you presently doing for this?

Is it helping? Yes

PMS? Yes
   (If no, please skip the next five questions.)

If yes, specifically describe your symptom/s.
(Heavy bleeding, blood clots, cramping, emotional, etc…)

If yes, how long has this been going on?   

What have you done for this in the past?

Did it help? Yes

What are you presently doing for this?

Is it helping? Yes

Ovarian cysts? Yes
   (If no, please skip the next five questions.)

If yes, when was this diagnosed?   

What have you done for this in the past?

Did it help? Yes

What are you presently doing for this?

Is it helping? Yes

Fibrocystic Breasts? Yes
   (If no, please skip the next five questions.)

If yes, when was this diagnosed?   

What have you done for this in the past?

Did it help? Yes

What are you presently doing for this?

Is it helping? Yes

Breast tenderness? Yes
   (If no, please skip the next five questions.)

If yes, how long has this been going on?   

What have you done for this in the past?

Did it help? Yes

What are you presently doing for this?

Is it helping? Yes

Uterine Fibroids? Yes
   (If no, please skip the next five questions.)

If yes, when was this diagnosed?   

What have you done for this in the past?

Did it help? Yes

What are you presently doing for this?

Is it helping? Yes

Endometriosis? Yes
   (If no, please skip the next five questions.)

If yes, when was this diagnosed?   

What have you done for this in the past?

Did it help? Yes

What are you presently doing for this?

Is it helping? Yes

PCOS (Polycystic Ovarian Syndrome)? Yes
   (If no, please skip the next five questions.)

If yes, when was this diagnosed?   

What have you done for this in the past?

Did it help? Yes

What are you presently doing for this?

Is it helping? Yes

Vaginal Dryness? Yes
   (If no, please skip the next five questions.)

If yes, how long has this been going on?   

What have you done for this in the past?

Did it help? Yes

What are you presently doing for this?

Is it helping? Yes

Are you still having a menstrual cycle?      Yes No

If yes, how many days are there to your cycle?          

If no, when did it stop?                                            

Have you had a hysterectomy?      Yes
   (If no, please skip the next three questions.)

If yes, when?                                                          

Was it a full or partial hysterectomy?      Full Partial

What was the reason for your hysterectomy?

Have you used, or are you currently using, conventional
hormone replacement therapy?      Yes
   (If no, please skip the next five questions.)

If yes, what were you prescribed?

When did you take this?                                           

Are you currently taking it?                                       

Did it help?    Yes No            Is it helping?    Yes No

Other

Decreased spontaneous morning erection? Yes
   (If no, please skip the next five questions.)

If yes, how long has this been going on?   

What have you done for this in the past?

Did it help? Yes

What are you presently doing for this?

Is it helping? Yes

Erectile Dysfunction? Yes
   (If no, please skip the next five questions.)

If yes, how long has this been going on?   

What have you done for this in the past?

Did it help? Yes

What are you presently doing for this?

Is it helping? Yes

Pain upon ejaculation? Yes
   (If no, please skip the next five questions.)

If yes, how long has this been going on?   

What have you done for this in the past?

Did it help? Yes

What are you presently doing for this?

Is it helping? Yes

Do you have a history of prostate problems? Yes
   (If no, please skip the next five questions.)

If yes, how long has this been going on?   

What have you done for this in the past?

Did it help? Yes

What are you presently doing for this?

Is it helping? Yes

Have you had a vasectomy? Yes
   (If no, please skip the next question.)

If yes, when?   

Have you had a reverse vasectomy? Yes
   (If no, please skip the next question.)

If yes, when?   

Other

Check the following that applies to your child:
          My child took soy formula as an infant
          My child was breastfed as an infant
          My child was vaccinated
          My child complains of headaches
          My child is not keeping up with growth charts for height
          My child is having trouble with school
          My child has been diagnosed with attention deficit disorder
          My child displays the symptoms of attention deficit disorder
          My child is having delayed puberty
          My child is unusually fatigued, exhausted, or sleeping far more than usual
          My child is severely constipated
          My child has recurring ear infections
          My child is often sick with a cough, cold, ear infection, etc…
          My child has allergies
          My child has asthma
          My child is complaining of pains, aches, and stiffness in various
                joints, hands, and feet
          My child seems depressed
          My child has difficulty concentrating

Other