Thank you for choosing Dimensions Chiropractic. Please complete this confidential patient form.

Patient Information
Date______________
Name ______________________________________________________________
Date of Birth _______________________
Address _____________________________________________________________
SSN _______________________________
City ______________________________
State _____
Zip _____________
Gender:
Male
Female
Home Phone _________________________________
Email __________________________________________________
Work Phone _________________________________
Is it ok if the Doctor contacts you via email?
Yes
No
Cell Phone ___________________________________
Do you want to receive our monthly email newsletter? Yes No
Emergency Contact ____________________________
Relationship ___________________
Phone ____________________
Referral Information
Who may we thank for referring you to our office? _______________________________________________________________
Financial and Insurance Information Name Subscriber or party responsible for payment
___________________________________________________
Subscribers Date of Birth _____________________
Insurance Carrier ____________________________________

Do you have health insurance? Yes No

Do you have a health savings account? Yes No
Are you eligible for Medicare (over age 65) Yes No

Employment Information
Employer ________________________________________
Occupation ______________________________________________
Business Address ____________________________________________________________________________________________
Hours of computer use daily? ________________________
Right or Left Handed? ______
Hours worked each week?______
Hours driving daily? _______________________________
Describe a typical work day ________________________________
Hours on your feet daily? ___________________________
________________________________________________________
Prior Chiropractic Care
Doctor ____________________________
Location ________________________ Dates of Treatment __________________
Why did you initiate care? ____________________________________________________________________________________
Why did you discontinue care? ________________________________________________________________________________
Reason for Todays Visit
Please rank your health concerns and rate their severity (on a scale from 1-10, 10 being the worst). Please include your current
pain/injury as well as other health concerns (ie. bad knee, overweight, decreased energy, teeth grinding, etc.) :
1.__________________________________________________________________________________________________________
2.__________________________________________________________________________________________________________
3.__________________________________________________________________________________________________________
Is your current pain or injury due to a car accident? Yes No
If yes, date of accident _________________________
Have you been in a car accident in the last three years? Yes No
If yes, date of accident ________________________
Please List prior car accidents by date _________________________________________________________________________
Health History
Have you ever been seriously injured or hospitalized? Yes No If Yes, please describe ____________________________
___________________________________________________________________________________________________________
List all prior surgeries ________________________________________________________________________________________
___________________________________________________________________________________________________________
Please list all medications and nutritional supplements you are currently taking ___________________________________________
___________________________________________________________________________________________________________
Dimensions Chiropractic

Current Symptoms
On the diagram to the right please mark all areas where you are currently having pain or other abnormal
sensation. Please also indicate where your pain travels (if appropriate).
Please make notes in the margins regarding:
Describe the pain, numbness, tingling, etc.
1. Rate your pain by circling the number that best describes
your pain at its WORST in the past 24 hours.
1 2 3 4 5 6 7 8 9 10
2. Rate your pain by circling the number that best describes
your pain at its LEAST in the past 24 hours.
1 2 3 4 5 6 7 8 9 10
3. Rate your pain by circling the number that best describes
your pain on AVERAGE for the past WEEK.
1 2 3 4 5 6 7 8 9 10

Asthma
Wheezing
Persistent cough
Coughing blood
Vascular
Chest pain
Palpitations
Ankle swelling
Cold feet/hands
Leg cramps
Calf pain
Varicose veins

Skin
Rash
Easy bruising
Itching/Peeling
Changes in moles

Decreased urination

G-I System
Gas
Heartburn
Indigestions
Ulcers
Vomiting/Nausea
Abdominal pain
Diarrhea
Constipation
Blood in Stool
Hemorrhoids
G-U system
Difficulty urinating
Pain urinating
Blood in urine
Incontinence
Increase urination

Nose
Nosebleeds
Sinus problems

Neurologic
Seizures/Epilepsy
Stroke
Tingling sensation
Numbness
Weakness
Difficulty walking
Poor coordination
Muscle/Bone
Joint Pain
Stiffness
Muscle ache
Arthritis
Bone Pain
Fracture
Dislocation
Conditions
Anemia
Osteopenia
Osteoporosis
Osteoarthritis
Polio

Past

Low Blood pressure

High Blood pressure

Difficulty breathing

Now

Head
Headache
Dizziness
Head trauma
Fainting
Blacking out
Eyes
Changes in vision
Light sensitivity
Spots in vision
Mouth
Bleeding Gums
Cold sores
Dentures
Jaw pain
Changes in taste
Hoarseness

Lungs

Past

Now

Past

Past

Now

Weight loss
Weight gain

Now

Now
Past

Review of Systems Please check any symptom or condition that you either have Now or have had Past:

Conditions (cont.)
Cataracts
Pneumonia
Tuberculosis
Gallbladder Disease
Liver Disease
Urinary infection
Genital infection
Diabetes
Thyroid Condition
Rheumatoid Arthritis

Glaucoma
Alcoholism
Tumor
Multiple Sclerosis
Parkinsons Disease
Gout
High Cholesterol
Migraine Headaches
TIAs
Cancer

Please List any other conditions that you have ever been diagnosed with or are currently being treated for _________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Womens Health
Date of last Pap Exam _________________
Date of last menstrual period ___________________
Are you Pregnant? Yes No
Number of Pregnancies ________
Number of vaginal births _______ Cesareans _______

Dimensions Chiropractic

Family History
Please list anyone in your immediate family who has a history of the following:
Cancer ____________________________________________________________________________________________________
Heart Disease ______________________________________________________________________________________________
Hypertension ______________________________________________________________________________________________
Diabetes___________________________________________________________________________________________________
Auto-Immune Diseases _______________________________________________________________________________________
Epilepsy ___________________________________________________________________________________________________
Arthritis ___________________________________________________________________________________________________
Allergies ___________________________________________________________________________________________________
Recent Illness ________________________________________________________________________________________________
Recent Injury ________________________________________________________________________________________________
Lifestyle
Hours of sleep each night 0-2 3-5 6-8 9+ Is your sleep Restful Restless Hard to fall asleep Wake up often
Sports played Golf Snow Ski Water Ski Tennis Running Walking Martial Arts Volleyball
Swimming Basketball Hockey Snowboard Cycling Fishing Hiking Other ___________________
Leisure Activities Reading Cooking Music TV Internet Other:
Do you smoke? Yes No How much per day? ________ How much alcohol do you consume weekly? ______________
How much coffee/tea/caffeine do you consume daily? _______________________________
Daily water intake: When Im thirsty 2-4 glasses 5-8 glasses 9-12 glasses Constantly, Im always thirsty

Additional Information / Questions

Are there any specific questions about your condition or chiropractic that you want Dr. Wilke and/or Dr. Wills to address at todays
visit in addition to a thorough history and physical exam?
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been
accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the doctor to
release any information including the diagnosis and the records of any treatment or examination rendered to me or my dependent
during the period of such chiropractic care to third party payers and or health practitioners. I authorize and request my
insurance company to pay directly to Dimensions Chiropractic insurance benefits that are otherwise payable to me. I understand
that my chiropractic insurance carrier may cover only a portion of or not cover all of the services rendered.
I agree to be ultimately responsible for all fees for services rendered and that fees are payable when services are rendered.

X
Signature of Patient (or guardian if minor)

Dimensions Chiropractic

Date