Questionnaire First Visit for Adults

1
NILSSON CHIROPRACTIC CENTRE
Today´s date: ….../……./…….
NAME & SURNAME: …………………………………………………..…. Date of birth: …….../…..…../…..….
Address: ……………………………………………………………….………………………..……………………
Town: ……………………………………………………………….…… Nationality: ……..……………………..
NIE / Passport: ………………………………………..…Civil status:……………………………………………..
Private Tel: ….………….………… Mobile:…………………… Profession: ……………..……………………
E-mail: ………………….……………………………………………………………………………………………
Recommended by:………………………………………………………………………………………………….
Reason for your visit today: …………………………………………………………………………………………
Have you had chiropractic care before?
NO
YES
Name of Chiropractor and when?……………………………………………………………………………………
Since when have you had this problem? ………………………………………………………………….............
Other therapies: …………….………………………………………………………………………………………...
Medication, supplements: ………..……………………………………………………………………………….....
Surgery, describe: …………………………………………………………………………………… Year ………
…………………………………………………………………………………………………………. Year ………
………………………………………………………………………………………………………… Year ………
………………………………………………………………………………………………….… ….. Year ………
Accidents, trauma (car, falls) – describe: ……………………………………………….………... Year ………
………………………………………………………………………………………………………… Year ………
…………………………………………………………………………………………………………. Year ………
…………………………………………………………………………………………………………. Year ………
Diseases – describe when they were diagnosed: ……………………………………………… Year ………
…………………………………………………………………………………………………………. Year ………
…………………………………………………………………………………………………………. Year ………
…………………………………………………………………………………………………………. Year ………
How much time do you spend sitting, standing or in the car? …………………………………………………
How do you sleep? On the side, face up, face down? Describe: ………………………………………………
Your Medical History mark with an X the following conditions that you have now or if you have
previously suffered from them indicating if it was in the past or present.
Diet
q Sodas per day
q
Coffee per day
q
Litres of water per
day
q
Alcohol per day
Lifestyle
q
q
Work stress
Toxins at work
q
q
Drugs
Family stress
q
q
Marihuana
q Tabacco per day
Daily exercise & what type:
Musculoskeletal
q
q
q
q
q
q
Neck
Elbow L/R
Wrist L/R
Ankle L/R
q
Hips L/R
Arthritis
q
q
q
q
q
Shoulder L/R
Dorsals
Gluteal muscles L/R
Limited range of
motion
Osteopaenia
Ankylosing spondylitis
q
q
q
q
q
q
Arms L/R
Ribs L/R
Knee L/R
Rheumatism
q
Osteoporosis
Spina bifida
q
q
q
q
q
Hands L/R
Lumbars L/R
Legs L/R
Foot L/R
Paget´s síndrome
Muscular dystrophy
2
General Symptoms
q
q
Bad circulation
Bruises easily / bad
circulation
Sleep badly
Fatigue q Numbness
q
q
q
q
Dizziness
Difficulty breathing
q
q
Vertigo
Cramps
Head, Eyes, Nose, Throat, Ears
q
q
q
q
q
Headaches
Eye pain
Poor eyesight
Jaw problems
Migraines
Glaucoma
q Catarats L/R
q Dental problems
q Grinds teeth
Other describe:
q
Facial pain
Sinusitis
Hypothyroidism
Hyperthyroidism
q
q
q
q
q
q
q
q
Re-occurring sore throats
Ringing in ears
Bad hearing
Otitis – pain in ears
Respiratory
q
Asthma /
whistling
q
Difficulty breathing sitting/lying
down
q
Opression on
chest
q
Other describe:
Cardiovascular
q
q
Tensión alta
Tensión
baja
q
q
Taquicardia/Palpitaciones
Desmayo
q
q
Dolor en pecho
Coágulos de
sangre
q
q
Marcapasos
Otro describa:
Gastrointestinal
q
q
q
Nausea
Vomiting
Gases
q
q
q
Diarrhea
Constipation
Irritable bowel síndrome
q
q
q
Intestinal pain/cramps
Acidity
Swelling
q
q
q
Ulcers
Hiatus hernia
Gall stones
Skin and Hair
q
Ulcers
q
Psoriasis
q
Excema
q
Loss of hair
(alopecia)
q
Changes in skin or hair:
Neuropsychological
q
q
q
Convulsions / Ischemic
or Haemorrhagic
stroke (brain attack)
Anxiety
Tics
q
Bad memory
q
q
Depression
q
q
Abuse survivor
q
Irritation
Gets easily
stressed
Other describe:
q
Ever considered
suicide or self-harm
q
In psychiatric care
3
Genitourinary
q
Urinary problems
q
q
Kidney stones
q
Prolapsed bladder
Frequent Bladder
infections
q
Prostate problems
q
Impotency
q
Increased libido
q
Decreased libido
Gynaecology
q
Premenstrual
síndrome
q
q
Premature
menopause
How many
pregnancies?:
q
q
q
Pain
before/during/after
menstruation
Hysterectomy – how
old?
How many children?:
q
Irregular
menstruation
q
Age of menopause:
q
Hot flashes
q
Prolapsed uterus
q
Are you currently
pregnant?:
q
How many
abortions/miscarriage
s?:
Please use this space to include more information that hasn´t already been asked or
written:_____________________________________________________________________________
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Signed _______________________________________________________________
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