Alan Nathans Family Chiropractic

11048-2 Baymeadows Rd. Jacksonville, Fl 32256

904-733-7393          (f) 904-363-3397

drnathans.com|drnathans@bellsouth.net

ADULT QUESTIONNAIRE

Date Questionnaire Received: ____ / ____ / ____ Date of Initial Consultation: ____ / ____ /

[The above line is for office use only]

PERSONAL INFORMATION:

First Name: _________________ Last Name:_________________ Middle Initial: _____

Home Address: ______________________________________ Phones: (Home) _______________________

______________________________________               (Cell) _______________________

Email: ________________________________                                          (Work) _______________________

Age: ___ Birth Date: ____/____/____           Female / Male                 SSN (optional): _________________

Place of Birth: _________________________ Race/National/Ethnic Roots:____________________________

Height: __________ Weight: __________ lbs ___    Right Handed / Left Handed / Mixed Dominance

Occupation: _______________________________

HEALTH INSURANCE INFORMATION:

Please note ? We accept Blue Cross and Blue Shield and Aetna health insurance.

Primary Health Insurance: ________________________ ID/Group #: ____________________

Secondary Health Insurance: ______________________

GENERAL:

Who can we thank for referred you?   _____________________________________________________

What brings you to our office today?  __________________________________________________________________________________________________________________________________________________________________________________________________

What do you hope to get from today’s visit? ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PRIMARY DOCTOR (S)

NAME PHONE NUMBERS CITY, STATE LAST VISIT

SPECIALISTS

NAME SPECIALTY PHONE NUMBERS CITY, STATE LAST VISIT

NUTRITIONIST

NAME PHONE NUMBERS CITY, STATE LAST VISIT

NATUROPATH (S) and or HOMEOPATH (S)

NAME PHONE NUMBERS CITY, STATE LAST VISIT

THERAPIST (S)

NAME TYPE of THERAPIST PHONE NUMBERS CITY, STATE LAST VISIT

OTHER:

NAME PHONE NUMBERS CITY, STATE LAST VISIT

CURRENT HEALTH CONCERNS

PROBLEM and BRIEF DESCRIPTION DATE OF ONSET FREQUENCY(Daily, weekly…) SEVERITY(mild, mod or severe)

How much time have you lost from work or school in the past year?  _____________________________

Why?  _________________________________________________________________________________________

_______________________________________________________________________________________________

MEDICATIONS

What are you taking NOW?

NAME DOSAGE and # per day GoodResponse NoResponse BadResponse Bad thenGood

VITAMINS, MINERALS, and OTHER NUTRITIONAL SUPPLEMENTS

What are you taking NOW?

NAME and FORM(eg. Calcium Carbonate vs. Calcium Citrate) DOSAGE (mg, mcg, IU, etc) and # per day GoodResponse

 NoResponse BadResponse Bad thenGood Res.

PAST MEDICAL HISTORY

Include any chronic/recurring disorder or previous problems/diseases which no longer affect you

CONDITION PAST TREATMENTS CURRENT TREATMENTS APPROXIMATEDATE (S) of TREATMENT

PAST MEDICAL HISTORY CONTINUED

Do you have a history of Learning Problems? _________________

If yes, please provide details (including how they were addressed)

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________

Provide details of any tattoos or body piercings you may have? __________________________________________________________________________________________________________________________________________________________________________________________________

Do you have amalgam fillings in your teeth? _____________________

If yes, how many and the date the fillings were placed______________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________________

Any history of dental problems? _______________________________________________________________________ _________________________________________________________________________________________________

_________________________________________________________________________________________________

Any plans for special dental procedures in the future? ______________________________________________________ _________________________________________________________________________________________________

Please (?) substances TAKEN IN THE PAST and mark appropriate reaction.

DATEIn PAST SUPPLEMENT DOSAGE (mg, mcg, IU, etc)And # per/day

 Good None Bad Goodthen Bad
Multivitamin (Specify)
Vitamin A
Vitamin C
Vitamin E
Vitamin B3 (Niacin)
Vitamin B6
5HTP/Serotonin
Alpha-Keto-Glutarate
DMG or TMG
Glutathione
GABA
Glutamine
SAMe
Taurine
Tryptophan
Tyrosine
Calcium (Specify Type)
Magnesium
Selenium
IV Immune Globulin
Oral Immune Globulin
DATEIn PAST SUPPLEMENT DOSAGE (mg, mcg, IU, etc)And # per/day

 Good None Bad Goodthen Bad
Secretin (Specify form)
Essential Fatty Acids (Specify type)
Probiotic (Specify brand)
Pycnogenol
Folic Acid
B12 (Specify Form)
Natural AntiBacterials(Specify)
Natural AntiFungals(Specify)
Natural AntiVirals(Specify)
Vitamin D
Vitamin K
Iron
Glucosamine and/orChondroitin
Melatonin

Have you ever used CHELATING AGENTS? If yes, please specify name, dose, route, frequency of use, reason for use, and approximate dates of starting and stopping treatment. __________________________________________________  __________________________________________________________________________________________________________________________________________________________________________________________________

Please list any other medications you have TAKEN IN THE PAST? Specifically indicate any frequent use of antibiotics and/or steroids. Also, please comment as to whether you had good, bad or no responses to each medication.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please mark which tests have been done and the results
TEST DATE RESULTS NOTES
Physical Examination
Eye Exam
Dental Exam
Breast Exam
Digital Rectal Exam
Stool Occult Blood
Cholesterol Profile
Bone Density (DEXA)
Mammogram
PSA
Colonoscopy or FlexibleSigmoidoscopy
PAP Test
Cardiac Stress Test(Specify type)
Hearing Test

FEMALE HEALTH HISTORY

Age at first period ______          Date of last period ___________            Length of cycles________________

History of irregular/abnormal periods? ___Yes, ___No       If yes, please describe: _______________________________

_________________________________________________________________________________________________

Please check if you have a history of ___Endometriosis____Fibroids____Polycystic Ovarian Syndrome?

Describe any premenstrual symptoms: _________________________________________________________________ ________________________________________________________________________________________________

Do you have a history of abnormal PAP tests?________ If yes, please describe: ________________________________

________________________________________________________________________________________________

Are you taking birth control pills? _____ If yes, for how long?_______ If no, have you ever taken them?______________

Any known history of Infertility problems? ______ If yes, please explain: ______________________________________

_______________________________________________________________________________________________

Pregnancies: None_____       Term Births______      Miscarraiges______       Abortions_________

Preemies_______ Birth weight of largest baby________            Smallest baby______

Are you currently pregnant?________ If so, what is your due date?____________

If you have never been pregnant, do you wish to have children in the future?________

If you have children, do you plan to have more?_______

Illnesses or complications during pregnancy or labor and delivery: ________________________

_____________________________________________________________________________

Medications taken during pregnancy or labor and delivery:_______________________________ ______________________________________________________________________________

If you have ever had a C-Section, please explain:______________________________________

Complications for you after delivery: _________________________________________________

Did you (or do you plan to) breastfeed your children? ____________________________________

Do you take any prescription medications or natural substances for Peri or Post-menopausal symptoms? ________

If yes, provide names, dosages,etc?_______________________________________________________

____________________________________________________________________________________

Any history of breast problems (tenderness, cysts, etc)?  ______________________________________

Any history of yeast infections? If yes, please explain_________________________________________

EARLY HEALTH HISTORY

Did your mother have any known problems during her pregnancy with you (illness, stress, medications, smoking, vaccines, alcohol)? ____________________________________________________________

___________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________

Were you breastfed or bottlefed? _____________________

If breastfed, please indicate duration:______________________________________________

Did you have any significant stresses in childhood or adolescence? ______________

If yes, please explain: __________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________

Please check if you had any of the following childhood illnesses?

___ Frequent Ear, Throat or other Infections ___Colic           ___Reflux                 ___Meningitis     ___Thrush       ___Asthma           ___Chicken Pox                ___Eczema      ___Frequent Colds   ___Other_________________

Did you take ____antibiotics or _____ steroid medications frequently?

Did you receive standard childhood immunizations?  _______________________________________

Did you ever have adverse reactions to vaccines? ______________

If yes, please explain:  _________________________________________________________________

Did you have a problem with bedwetting? ____________________

Until what age?______________________________

MEDICAL HISTORY(Continued)
Major surgeries – Please describe and give dates:
SURGERY DATE(S) RESULTS
Major injuries – Please describe and give dates:
INJURY DATE(S) RESULTS
Illnesses – Please list appropriate dates and any complications:
ILLNESS DATE(S) COMPLICATIONS
Ear infections
Sinus infections
Bronchitis
Pneumonia
Thrush
Chicken Pox
Seizures
Mono
Immunizations
Please indicate date and any reactions for those immunizations that your child has received. If exact date isn’t known, please approximate. “Bowel” refers to any bowel symptom such as diarrhea.

“Swelling” refers to the site of the injection.
Diptheria/Pertussis/Tetanus Date Bowel Swelling Crying Seizure Irritable Fever Other
DPT 1
DPT 2
DPT 3
DPT 4
DPT 5
Adult Diptheris/Tetanus
Paediatric Diptheris/Tetanus
H Influenza Type B Date Bowel Swelling Crying Seizure Irritable Fever Other
Hib 1
Hib 2
Hib 3
Hib 4
Polio (circle Oral or Injection) Date Bowel Swelling Crying Seizure Irritable Fever Other
OPV 1 / Injection 1
OPV 2/ Injection 2
OPV 3/ Injection 3
OPV 4/ Injection 4
OPV 5/ Injection 5
Measles/Mumps/Rubella Date Bowel Swelling Crying Seizure Irritable Fever Other
MMR 1
MMR 2
Hepatitis B Vaccine Date Bowel Swelling Crying Seizure Irritable Fever Other
HBV 1
HBV 2
HBV 3
Prevnar (pnemococcal)
Miscellaneous Date Bowel Swelling Crying Seizure Irritable Fever Other
Varivax (chicken Pox)
Tine Test
Flu Vaccine
Other
THERAPIES
Please list THERAPIES you have used or are using now…and check the appropriate RESPONSE you had.
NOW PAST THERAPY Good None Bad Comments
Acupuncture
Psychiatrist
Homeopathy
Naturopathy
Occupational Therapy
Physical Therapy
Psychologist
Craniosacral
Energy Therapy
OTHER

CURRENT SIGNS AND SYMPTOMS
Please check where appropriate. Leave row blank if not applicable.
DESCRIPTION MILD MODERATE SEVERE DETAILS
Fatigue
Difficulty falling asleep
Difficulty staying asleep
Early waking
Nighttime waking
Daytime sleepiness
Night walking
Nightmares
Fever
Heat intolerance
Cold intolerance
Flushing
Headache – Specify type
Distorted feeling of self
Auditory hallucinations
Visual hallucinations
DESCRIPTION MILD MODERATE SEVERE DETAILS
Distorted senses – Specify ifVision, hearing, taste, smell
Low self esteem
Trouble remembering
Seizures
Anxiety
Irritability
Depression
Panic Attacks
Phobias (Specify)
Paranoia
Suicidal thoughts
Dizziness
Fainting
Difficulty with concentration
Difficulty with balance
Numbness/Tingling
Mood swings
Conjunctivitis
Ear ringing
Hearing loss
Sensitive to lights or loud noises
Sore throats
Congestion
Dark circles/ puffiness under eyes
Sinus infections
Post nasal drip
Loss of smell
Loss of taste
Bad breath
Nose bleeds
Hoarseness
Cough—Dry
Cough—Productive
Seasonal Allergies
Palpitations
Varicose Veins
Angina
Heart Attack
Muscle cramps
TMJ problems
Chest
Tightness
Muscle weakness
Muscle stiffness
Joint stiffness
Joint pain
Poor appetite
Bad teeth
Gum bleeding
Dry mouth
Geographic tongue (maplike rash on the tongue)
DESCRIPTION MILD MODERATE SEVERE DETAILS
Cold sores
Cracking at corner of lips
Heartburn
Nausea
Vomiting
Abdominal pain
Bloating
Belching
Diarrhea
Constipation
Undigested food in stool
Mucous in stool
Blood in stool
Hemorrhoids
Difficulty swallowing
Eczema
Hives
Rash
Athletes foot
Acne
Easy bruising
Ears get red
Sensitive to bug bites
Pale skin
Dry skin
Itchy skin
Cracking or peeling of feet
Cracking or peeling of hands
Nail biting
Soft nails
White spots on nails
Thickening of nails
Fungus on nails
Ridges on nails
Pitting of nails
Urinary urgency
Urinary leaking
Urinary pain
Urinary hesitancy
Bedwetting
Kidney stones
Blood in urine
Prostate enlargement
Jock itch
Sexual problems (specify)
Vaginal discharge
Vaginal itching
Postmenopausal
bleeding
Tics
Night blindness
Gum disease
DESCRIPTION MILD MODERATE SEVERE DETAILS
Dry lips
Teeth grinding
Tremors
Psoriasis
Strong body odor
OCD behavior
Reflux
Thrush
OTHER
OTHER

Describe any other symptoms or anything else you would like us to know about you?

List any pertinent thoughts or questions you want to address:

The above information is true and accurate to the best of my knowledge.

________________________________________                ____________________________

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