Chiropractic Adult Form – Orleans Chiropractic Adult Form - Orleans This form will take approximately 20 minutes to complete. If you would like to save your form and continue at another time, you may do so via the link at the bottom of each page. An email will then be sent to you with a link to complete the form when you wish to continue. This form is secure and all information is confidential. Thank you. Step 1 of 9 - PERSONAL INFORMATION 0% Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Home PhoneCell PhoneWork PhoneEmail* I consent to receiving email communication from Oaktree*Emails we will send you will include news updates from Oaktree. We will not spam you and you can unsubscribe at anytime. You will still receive appointment reminders and other important notices via email.YesNoGenderFemaleMaleWeight (lbs)HeightBirthday* MD nameWorkplaceOccupationWho referred you to Oaktree?Marital StatusSingleCommon lawMarriedDivorcedSeparatedWidowedOtherDo you have kids?YesNoAges of your kids Do you have extended health care benefits that contribute to chiropractic care?YesNoUnsureAmount of chiropractic benefits per year: Save and Continue Later CHIROPRACTIC HISTORYHave you ever been to a chiropractor before?YesNoWere x-rays taken?YesNoUnsureName of ChiropractorCity City Date of last visit (approximate year/month)Duration & Frequency of CareFor how long did you see your chiropractor and how many times per week?MOTORIZED VEHICLE ACCIDENTSHave you ever been involved in a motor vehicle accident?Please list the year, description of the accident, and any injuries sustained. Add an additional line for any additional accidents/traumas.YearDescriptionInjuries Types of accident you were involved inPlease check all that apply High Speed Collisions >40km/h Vehicle unrepairable Whiplash Injury Un-belted accident FALLS (Regardless of age)Provide as much information as possible and if applicable.Falls from heights?Falls down stairs?Other falls?Broken bones?Childhood Falls?Have you ever fallen from any of the following? Trees Roof Play structure Bicycle Other Please specify the "other" that you have fallen from. Save and Continue Later POSTURE & HABITSDo you have/do any of the following?Check any/all that apply Sitting >6 hours/day Stomach sleeper Head forward posture Computer/phone >3 hours/day Activities that are repetitive in nature? Serving or catering Crafting etc .. Leaning or sitting on one hip Cross legs often Other Please specify the "other"SPORTS & RECREATIONSports or recreation injuriesPlease list any sports injuries you have sustained. Add an extra line for additional injuries. Do you participate in any of the following high impact activities?Check any/all that apply. Hockey Wrestling Basketball Running Mountain Biking Climbing Football Gymnastics Other Please specify the other activities you take part inOCCUPATIONAL STRESSESOccupationWork tasksPlease list any workplace tasks. Add an extra line for additional tasks. Work InjuriesPlease list any workplace injuries you have sustained. Add an extra line for additional injuries. Previous applicable occupation My job requires:Check any/all that apply. Heavy lifting Awkward positions Repetitive stresses Sitting for long periods Standing for long periods BIRTH TRAUMAWas your own birth/deliveryCheck any/all that apply Difficult/long Forceps C-section Epidural Suction Resuscitation Have you ever given birth?YesNoWas it:Check any/all that apply Difficult/long Forceps C-section Epidural Suction Resuscitation How many births have you had?On a scale of 1 to 10 (1= not committed at all, 10= highly committed), how committed are you to your health?Please enter a number from 1 to 10.On a scale of 1 to 10 (1= poor, 10= excellent), how would your rate your overall health?Please enter a number from 1 to 10.What is this effecting that is MOST important in your life? (list all that apply) What health goal, if you were to complete it or accomplish it, would have the greatest impact on your life? Save and Continue Later PRIMARY HEALTH CONCERNSWhat is your present primary health concern?Location:How long have you had this condition?Please specify in terms of weeks, months, or years.Have you had a similar condition in the past?YesNoUnsureWhat aggravates your condition?Please list anything that aggravates your condition. Add an extra line for additional aggravates. What relieves your condition?Please list anything that helps relieve your condition. Add an extra line for additional relievers. Are you getting pain or numbness in your arms or legs?YesNoIs your condition getting progressively worse? YesNoIt’s constantIt comes and goesPains are:Check any/all that apply. Sharp Dull Burning Tightness Pain severityChoose from 0 to 10. (0 = no pain, 10 = severe)012345678910How is this condition interfering with your life?Check any/all that apply. Work Daily Routine Other Please specify.List other health care professionals who treated this condition:Please list any other health care professionals who have helped treat your condition. Add an extra line for additional professionals.NameSpecialty SECONDARY HEALTH CONCERNSDo you have a secondary health concern?YesNoWhat is your present secondary health concern?Location:How long have you had this condition?Please specify in terms of weeks, months, or years.Have you had a similar condition in the past?YesNoUnsureWhat aggravates your condition?Please list anything that aggravates your condition. Add an extra line for additional aggravates. What relieves your condition?Please list anything that helps relieve your condition. Add an extra line for additional relievers. Are you getting pain or numbness in your arms or legs?YesNoIs your condition getting progressively worse? YesNoIt’s constantIt comes and goesPains are:Check any/all that apply. Sharp Dull Burning Tightness Pain severityChoose from 0 to 10. (0 = no pain, 10 = severe)012345678910How is this condition interfering with your life?Check any/all that apply. Work Daily Routine Other Please specify.List other health care professionals who treated this condition:Please list any other health care professionals who have helped treat your condition. Add an extra line for additional professionals.NameSpecialty OTHER HEALTH PROBLEMS, CONCERNS OR ADDITIONAL INFORMATIONAddtional informationPlease outline any additional health problems, concerns or additional information. Save and Continue Later CONDITIONS & SYMPTOMSPlease check any of the following signs of organ malfunction or dis-ease you are experiencing or have experienced in the last 6 months. Please select any/all the apply.Head / Neck Blurred / failing vision Deafness / ringing in ears Earaches Sore Throat / tonsillitis Thyroid problems Sinus problems Environmental allergies Cardiovascular system Chest pain Shortness of breath Heart medication High blood pressure medication High cholesterol medication Swelling of legs Respiratory system Frequent bronchitis History of pneumonia Chronic cough Spitting up phlegm / blood Difficulty breathing Tuberculosis Pneumonia Asthma Digestive system Heartburn / indigestion Stomach cramps Constipation / diarrhea Food allergy Food intolerances Irritable bowel syndrome Crohn’s disease Ulcers Belching / gas Nausea or vomiting Liver / gall bladder problems Colon trouble Black / bloody stool What food allergies do you have?Please list any food allergies you have. Add an extra line for additional allergies/foods. What food intolerances do you have?Please list any food intolerances you have. Add an extra line for additional intolerances/foods. Females Only Painful menstruation Cramps or backaches Peri-menopause Passed menopause Excessive / irregular flow Abnormal discharge Miscarriage Are you currently pregnant?YesNoDate of last menstrual period Number of miscarriagesMusculoskeletal system Painful joints Painful muscles Tendinitis Bursitis Arthritis Headaches / migraine Neck pain / stiffness Tension across left shoulder Tension across right shoulder Numbness-tingling in left arm/hand Numbness-tingling in right arm/hand Numbness-tingling in left leg/foot Numbness-tingling in right leg/foot Mid-back pain / stiffness Lower-back pain / stiffness Scoliosis / spinal curvatures Faulty posture Painful tailbone Foot trouble Location of tendinitis Location of BursitisLocation of ArthritisGeneral symptoms Fever / chills / sweats Frequent colds Fainting / dizziness Seizures / convulsions Skin problems Tremors Loss of balance Unexpected weight loss / gain Anemia Alcoholism HIV / AIDS Loss of sleep Poor memory / concentration Learning disability Irritable / nervous / tension Depression / emotional problems Anxiety Decreased energy / fatigue Tired / lethargic Autoimmune disease Antibiotic use Cancer Other Location/type of cancerPlease specify other condition(s) Save and Continue Later EXERCISEHow often do you participate in aerobic exercises?For at least 30 minutes per day0 days/week1-2 days/week3-4 days/week5-7 days/weekDo you lift weights or do resistance training?Check any/all that apply. Crossfit Gym Other Please specify the other training you doHow often do you stretch per week?0 days/week1-2 days/week3-4 days/week5-7 days/weekEMOTIONAL STRESSAre you currently experiencing significant stress in the following areas?Check any/all that apply. Marriage Relationships Kids Finances Work School Elderly Parents - caregiver Recent major life events [births, deaths...] Save and Continue Later FAMILY HEALTH HISTORYWhat significant health concerns have your family members experienced? Parents / Siblings:Please list any health concerns your parents or siblings have experienced. Add an extra line for additional concerns. EQUIPMENTHow old is your mattress?Is your mattress:ComfortableUncomfortableWhat type of mattress do you own?CoilFoamRubberWhat type of pillow do you use?Ergonomic neck supportFeatherFoamDo you wear?Check any/all that apply. Custom orthotics Over the counter foot supports Foot lifts Heel lifts What is the height of your foot lifts?What is the height of your heal lifts?What kind/brand of over the counter foot supports do you use? Save and Continue Later CHEMICAL STRESSESDo you feel that you make healthy food choices?YesNoI don't KnowHow would you describe your nutrition?Are you at your ideal body weight?YesNoI don't KnowDo you take any supplements?YesNoWhich supplements do you take?Check any/all that apply. Omega3 B vitamin Probiotics Vitamin D Multivitamin Iron Other What other supplements do you take?Please list any other supplements you take. Add an extra line for each additional supplement. Do you presently:Check any/all that apply. Smoke Use recreational drugs Have a history of addiction Please use this box to expand on the question above (if you checked anything off).Do you consume alcohol?YesNoHow often do you consume alcohol?Rarely1-3 days/weekDailyMore than 1x per dayMEDICATIONSDo you currently take any medications?YesNoWhat other medications do you take?Please list any medications you take. Add an extra line for each additional medication.Name of medicationUsed for what condition SURGERIESHave you ever had surgery?YesNoWhat surgeries have you had performed?Please list any surgeries you have had, including the date and for what condition. Add an extra line for each individual surgery.Year PerformedFor what condition Save and Continue Later Additional information and detailsPlease enter any other details that may assist the Doctor in understanding your lifestyle and health status: Additional information and details.Please read the statement below and type your name in the response box below. When you come in for your appointment, you will sign and date next to the statement.*I understand that the purpose of today's visit is to determine if I am a candidate for chiropractic care and that I am responsible for any fees agreed upon between myself and the attending doctor. All examination fees will be explained to me before any tests are performed.NameThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.