Crawford Family Chiropractic

Chiropractic care for the whole body and the whole family.

970-921-5416

562-822-8881

[email protected]

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Contact
Forms

Welcome Form

Please read carefully and complete the form

Name*

Home Address*

Home Phone number*

Email Address*

Date*

What do you prefer to be called*

Gender*

MaleFemale

Birthday

Age

Cell number

Referred by

Employer

How long have you been employed?

Employer's Address

Work Phone Number

Occupation

Marital Status

SingleMarriedDivorcedSeparatedWidowed

Spouse's Name

Reason For Visit

Have you ever been treated by a chiropractor before? *

yesno

If so, please explain

The reason for this visit is a result of

WorkSportsAutoTraumaChronicNone of the above

Explain What happened

Please describe the pain and location

When did this condition begin

Is this condition getting worse*

yesnoconstantComes And Goes

Is this condition interfering with your

worksleepdaily routine

If so, please explain

What makes your condition worse

What makes your condition better

Have you ever had similar conditions in the past?*

YesNo

If so, please explain

Describe the type of pain you are experiencing*

NumbnessPins and needlesBurningAchingStabbingOther

Please indicate the severity of the pain you are experiencing, with 0 being no pain and 10 being the worst pain you have ever felt.

012345678910

Have you been treated by a physician for this condition

YesNo

If so, please describe the treatment rendered*

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Health History

Are you taking any of the following medications? If so, please indicate dosage.*

Nerve pillsPain killers (including aspirin)Muscle relaxersStimulantsBlood thinnersTranquilizersHeart medicationBlood pressureInsulinAnti-depressantsOther (including vitamins)None

Please list your medication(s), vitamins and dosage*

Height and Weight

Do you smoke? If so, how much and how long?

Have you ever had any of the following diseases/medical conditions?*

Heart attackHeart Surgery/PacemakerHeart MurmurMitral Valve ProlapseArtificial ValvesStrokeCongenital heart defectAlcohol and/or drug abuseHIV+/AIDSHigh/low blood pressureSevere/Frequent neck painSevere/Frequent headachesFainting/Seizures/EpilepsyDiabetes/Low Blood SugarEmphysema/Lung DiseaseAsthma/TuberculosisDifficulty BreathingFrequent ColdsFrequent Lower Back PainFrequent Hip/Knee painArthritisArtificial Joints/BonesVenereal Disease/ShinglesGlaucoma/Eye DiseasePsychiatric ProblemsKidney ProblemsHepatitisAnemiaCancerChemotherapyUlcers/ColitisConstipation/DiarrheaIrritable Bowel SyndromeDigestion ProblemsNone of the above

Please list any serious medical conditions with which you have ever been diagnosed:

Please list anything that you may be allergic to:

List any past serious accidents or injuries with dates:

Are you wearing any of the following:

Heel LiftsSole LiftsInner solesArch supportsOrthoticsNone

How old is your mattress? Is it comfortable?

Please tell me about your diet:

Please tell me about your physical activity:

Please tell me about your sleeping habits:

For women: What was the date of your last period?

Are you currently pregnant or nursing?

How many pregnancies have you had?

Tell me about you periods? Heavy, painful etc.

Are you having menopausal symptoms? If so, what are they.

I understand the above information and guarantee this form was completed correctly and to the best of my knowledge. I also understand, it is my responsibility to inform Connie Grantham, D.C. of any changes in my medical status.

YesNo

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Event Of Emergency

Name of contact*

Relation*

Home Phone*

Work phone

Cell Phone

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562-822-8881

970-921-5416

[email protected]

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