Lake Michigan Wellness PLLC
Patient Registration and History
Please fill this form out completely (If you have concerns about releasing any
Information please consult with the doctor.)
List any accidents or falls: Motor vehicle______________________________________
Sports:__________________________ Other:________________________________
Broken bones or dislocations/fractures:_______________________________________
Ever had a spinal tap or injection? Y or N (If yes:_______________________________
Ever had a lapse in memory? Y or N (If yes:___________________________________
Have you ever been knocked unconscious? Y or N (If yes:_________________________
Have you ever had X-Rays taken? Y or N (If yes:________________________________
Have you ever seen a Chiropractor? Y or N (If yes who:__________________________
Place an X on front of all the following signs and symptoms that you have on a
recurring basis. A complete history helps us provide you with the best care!
General Symptoms Eye/Ear/Nose/Throat Have you had or have any of following
___ Headache ___ Ringing in ear(s) ___ Appendicitis
___ Night sweats ___ Earache ___ Diabetes
___ Fainting ___ Ear discharge ___ Back surgery
___ Dizziness ___ Hoarseness ___ Tubes in ear
___ Convulsions ___ Asthma ___ Heart disease
___ Loss of sleep ___ Frequent colds ___ Epilepsy
___Numbness or pain in ___ Sinus trouble ___ HIV /Aids
Arms/legs/hands/feet ___ Enlarged thyroid ___ Arthritis
___ Loss of weight ___ Sore throat ___ Tuberculosis
___ Wheezing ___ Nasal obstructions ___ Hernia
___ Sinus surgery
Muscles & Joints Respiratory ___Female surgery
___ Chronic cough ___ Cancer
___Weakness
___ Chest pain ___ Gall bladder surgery
___ Twitching (spasm)
___ Difficult breathing ___ Thyroid problems
___ Stiff neck
___ Spitting blood ___ Rectal surgery
___ Back ache
___ Stomach or ulcer surgery
___ Swollen joints
Habits ___ Multiple sclerosis
___ Tremors
___ Smoking
___ Foot trouble
___ Alcohol Family History (Circle)
___ Pain in tail bone
___ Caffeine Diabetes: Mother Father Sibling
___ Pain btwn shoulders
___ High Stress Heart Dis. M F S
Cancer: M F S
Cardiovascular
Exercise Back issues M F S
___ Rapid heart beat
___ None
___ Slow heart beat
___ Moderate Women Only
___ High BP
___ Daily ___ Currently Pregnant
___ Low BP
___ Heavy ___ Painful Menses
___ Pain over heart
___ Excessive menses
___ Swelling of ankles
___ Irregular menses
___Varicose veins
___ Cramps/Back ache
___ History of strokes
___ Hot flashes