1. REGISTRATION FORM SHEA FAMILY CHIROPRACTIC 858-312-5066
10720 THORNMINT ROAD SUITE B, SAN DIEGO CA 92127
PERSONAL INFORMATION
LAST NAME: ________________________________________________________________________
FIRST NAME: ___________________________________________________ MI: _________________
GENDER: MALE / FEMALE BIRTHDAY: _________ /_________ /_________ AGE: ________
SOCIAL SECURITY NUMBER: ________________________________________________________________________
MARITAL STATUS: SINGLE MARRIED DIVORCED SEPERATED WIDOWED
SPOUSES NAME: ________________________________________________________________________
EMERGENCY CONTACT: NAME: _____________________________ PHONE: _____________________________
WHO REFERRED YOU?: _______________________________________________________________________
CONTACT INOFRMATION
ADDRESS: ________________________________________________________________________
CITY: _______________________________________ STATE: ______ ZIP CODE: ___________
HOME PHONE: ________________________________________________________________________
CELL PHONE: ________________________________________________________________________
HOME EMAIL ADDRESS: ________________________________________________________________________
WORK: PHONE:_____________________________ EMAIL: ______________________________
CONDITION INFORMATION
REASON FOR VISIT: ___________________________________________ MARK AREAS OF SYMPTOMS:
DATE SYMPTONS STARTED?: ___________________________________________
GETTING WORSE OR BETTER?: ___________________________________________
RATE PAIN 0-10: ___________________________________________
TYPE OF PAIN: SHARP / DULL / BURNING / CRAMPING / THROBBING
MY PAIN INTERFERES WITH: WORK / SLEEP / DAILY ROUTINE / RECREATION
FREQUENCY OF MY PAIN: CONSTANT / COMES AND GOES
CHIROPRACTIC GOALS?: ________________________________________________________________________
ACCIDENT?: YES / NO AUTO / HOME / WORK / OTHER ________________________________

2. HEALTH HISTORY FORM SHEA FAMILY CHIROPRACTIC 858-312-5066
10720 THORNMINT ROAD SUITE B, SAN DIEGO CA 92127
PATIENT NAME:________________________________________________________________DATE:______________
HEALTH HISTORY
CARE CURRENTLY RECEIVING: CHIROPRACTIC / MASSAGE / MEDICATION / SURGERY / OTHER: ____________________
LAST DATE OF: SPINAL EXAM: _______ XRAY: _______ MRI: _______ BONE SCAN: _________
PLEASE CIRCLE ANY CONDITIONS THAT YOU CURRENTLY SUFFER FROM, AND CHECK ANY THAT YOU PREVIOUSLY HAD:
AIDS/HIV ALCOHOLISM ALLERGY SHOTS ANEMIA ANOREXIA
APPENDICITIS ARTHRITIS ASTHMA BLEEDING BREAST LUMP
BRONCHITIS BULIMIA CANCER CATARACTS CHEMICAL DEPENDENT
CHICKEN POX DIABETES EMPHYSEMA EPILEPSY FRACTURES
GLAUCOMA GOITER GONORRHEA GOUT HEART DISEASE
HEPATITIS HERNIA HERNIATED DISCO HERPES HIGH CHOLESTEROL
KIDNEY DISEASE LIVER DISEASE MEASLES HEADACHES MISCARRIAGE
MONO MS MUMPS OSTEOPOROSIS PACEMAKER
PARKINSONS PINCHED NERVE PNEUMONIA POLIO PROSTATE PROBLEM
PROTHESIS PSYCHIATRIC CARE RHEUMATOID ARTH RHEUMATIC FEVER SCARLET FEVER
STROKE SUICUDE ATTEMPT THYROID PROBLEM TONSILLITIS TB
TUMORS, GROWTHS TYPHOID FEVER ULCERS VAGINAL INFECTIONS VENEREAL DISEASE
WHOOPING COUGH COLDS FLU VIRAL INFECTIONS VISION PROBLEMS
FIBROMYALGIA MIGRAINES OTHER
ACTIVITY
EXERCISE WORK ACTIVITY HABITS
NONE ___ SITTING ___ HOURS A DAY? ____________ SMOKING ___ HOW OFTEN? ____________
MODERATE ___ STANDING ___ HOURS A DAY? ____________ ALCOHOL ___ HOW OFTEN? ____________
DAILY ___ LIGHT LABOR ___ HOURS A DAY? ____________ CAFFINE ___ HOW OFTEN? ____________
EXTREME SPORT ___ HEAVY LABOR ___ HOURS A DAY? ____________ STRESS ___ HOW OFTEN? ____________
INJURIES / SURGERIES
FALLS: _________________________________________________ DATE: _________________
HEAD INJURIES / WHIPLASH: _________________________________________________ DATE: _________________
FRACTURES / DISLOCATIONS: _________________________________________________ DATE: _________________
SURGERIES: _________________________________________________ DATE: _________________
CANCER: _________________________________________________ DATE: _________________
MEDICATIONS / VITAMINS / HERBS / MINERALS
PLEASE LIST ALL MEDICATIONS, VITAMINS, HERBS AND MINERALS THAT YOU ARE CURRENTLY TAKING:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
I HEREBY AUTHORIZE THE DOCTOR; AND/OR HIS ASSOCIATES TO EXAMINE ME, AND TO PERFORM ANY NECESSARY DIAGNOSTIC PROCEDURES,
INCLUDING X-RAY TO FULLY EVALUATE MY CONDITION FOR THE PRESENCE OF VERTEBRAL SUBLUXATION.
PATIENT SIGNATURE: ___________________________________________________________ DATE: _______________