Chiropractic Health Care
Dr. Laurie MacKinnon
Patient Intake Form (page 2)
Name: ___________________________________ Date:_____________________
Patient information contained within this form is considered strictly confidential. Your responses are important to help us
better understand the health issues you face and ensure the delivery of the best possible treatment.
Please indicate any of the following conditions you currently have:
General Gastrointestinal Cardiovascular Check any of the
□ Allergies □ Abdominal pain □ High blood pressure conditions you have or
□ Depression □ Constipation □ Low blood pressure have had:
□ Dizziness □ Diarrhea □ Irregular pulse □ Alcoholism
□ Fainting □ Difficult digestion □ Palpitation □ Anemia
□ Fatigue □ Bloated abdomen □ Poor circulation □ Appendicitis
□ Fever □ Gallbladder trouble □ Rapid heart beat □ Arteriosclerosis
□ Headaches □ Hernia □ Slow heart beat □ Asthma
□ Loss of sleep □ Hemorrhoids □ Swelling of ankles □ Bronchitis
□ Mental Illness □ Liver trouble □ Cancer
□ Nervousness □ Nausea Respiratory □ Chicken pox
□ Tremors □ Painful defecation □ Chest pain □ Diabetes
□ Weight loss / gain □ Pain over stomach □ Chronic cough □ Eczema
□ Poor appetite □ Hay fever □ Edema
Muscle/Joint □ Vomiting □ Shortness of breath □ Emphysema
□ Arthritis / rheumatism □ Wheezing □ Epilepsy
□ Bursitis Genitourinary □ Gout
□ Foot trouble □ Bed-wetting Women only □ Heart disease
□ Muscle weakness □ Bladder infection Are you pregnant □ Hepatitis
□ Low back pain □ Blood in urine □ Yes □ No □ Herpes
□ Neck pain □ Kidney infection If yes, how many □ High cholesterol
□ Mid back pain □ Prostate trouble months?___ □ HIV/AIDS
□ Joint pain How many children do you □ Influenza
Urination have?_____ □ Measles
Skin □ Decreased flow/force □ Mumps
Date of last PAP test:_____
□ Bruise easily □ Painful urination □ Numbness/tingling
□ normal □ Abnormal
□ Hives or allergies □ Urgency to urinate □ Pace maker
□ Itching Date of last □ Osteoporosis
□ Rash mamogram:_____ □ Pneumonia
□ Varicose veins □ normal □ Abnormal
□ Polio
□ Rheumatic fever
Eye, Ear, Nose & □ Stroke
Throat □ Thyroid disease
□ Colds □ Tuberculosis
□ Ear ache □ Ulcers
□ Hoarseness
□ Nose bleeds
□ Ringing of the ears
□ Sinus infection
□ Sore throat
□ Tonsillitis
□ Vision problems Please list any medication you are currently taking and why:
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