CHIROPRACTIC INTAKE & HISTORY

PATIENT INFORMATION

Patient Name LAST NAME

FIRST NAME MIDDLE INITIAL

Address

City __________ _ State ______ _

Home Phone

Cell Phone

Email

Sex OM OF

0 Married

O Separated

Age __

0 Widowed

0 Divorced

Birthday _____ _

0 Single 0 Minor

O Partnered

HOW CAN WE HELP YOU?

What brings you in today?

Employer/ School _______________ _

Occupation __________________ _

Spouse's Name ________________ _

Spouse's Employer _______________ _

Spouse's Occupation ______________ _

IN CASE OF EMERGENCY, CONTACT

Name ___________________ _

Relationship _________________ _

Contact Number ________________ _

Who may we thank for referring you? ________ _

If you are already experiencing a symptom, what is it? ------------------------------

How bad is it? How intense are your symptoms? (circle) 0 0 NO

SYMPTOMS

Please circle areas to the right where you have pain or other symptoms:

What does it feel like? (check where appropriate)

0 Numbness 0 Sharp

0 Tingling 0 Shooting

0 Stiffness 0 Burning

0 Dull 0 Throbbing

0 Aching 0 Stabbing

0 Cramping 0 Swelling

0 Nagging 0 Other

IMPACT OF YOUR SYMPTOMS

How is this symptom / condition interfering with your life? (check where appropriate)

No Mild Moderate Severe Effect Effect Effect Effect

Work 0 0 0 0

Exercise 0 0 0 0

Recreation 0 0 0 0

Relationships 0 0 0 0

Sleep 0 0 0 0

Self-Care 0 0 0 0

How committed are you to correcting this issue? 0 0 NOT

COMMITTED

Energy

Attitude

Patience

Productivity

Creativity

Other

0 0 8

No Mild Effect Effect

0 0

0 0

0 0

0 0

0 0

0 0

0 0 8

INTENSE

SYMPTOMS

Moderate Severe Effect

0

0

0

0

0

0

0

Effect

0

0

0

0

0

0

VERY

COMMITTED

Name: ___________________________________________ Age: ______ Sex: _____ Date: ____________________ PART I What is going on with your health in order of importance:

What are your goals in life?___________________________What your goals for this treatment? ____________________ __________________________________________ ____________________________________________

PART II Please circle the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Metabolic Assessment Formtm

Symptom groups listed on this form are not intended to be used as a diagnosis of any disease or condition.

Category IFeeling that bowels do not empty completely Lower abdominal pain relieved by passing stool or gas Alternating constipation and diarrhea Diarrhea Constipation Hard, dry, or small stool Coated tongue or “fuzzy” debris on tongue Pass large amount of foul-smelling gasMore than 3 bowel movements daily Use laxatives frequently

Category IIIncreasing frequency of food reactions Unpredictable food reactions Aches, pains, and swelling throughout the body Unpredictable abdominal swellingFrequent bloating and distention after eating

Category III Intolerance to smellsIntolerance to jewelryIntolerance to shampoo, lotion, detergents, etcMultiple smell and chemical sensitivitiesConstant skin outbreaks

Category IV Excessive belching, burping, or bloatingGas immediately following a mealOffensive breathDifficult bowel movementsSense of fullness during and after mealsDifficulty digesting proteins and meats;

undigested food found in stools

Category VStomach pain, burning, or aching 1-4 hours after eating Use of antacidsFeel hungry an hour or two after eatingHeartburn when lying down or bending forward Temporary relief by using antacids, food, milk, or carbonated beveragesDigestive problems subside with rest and relaxation Heartburn due to spicy foods, chocolate, citrus,

peppers, alcohol, and caffeine

Category VI Difficulty digesting roughage and fiberIndigestion and fullness last 2-4 hours after eating Pain, tenderness, soreness on left side under rib cage Excessive passage of gasNausea and/or vomitingStool undigested, foul smelling, mucus like, greasy, or poorly formedFrequent loss of appetite

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3 0 1 2 3

0 1 2 30 1 2 3

Category VIIAbdominal distention after consumption of fiber, starches, and sugarAbdominal distention after certain probiotic or natural supplementsDecreased gastrointestinal motility, constipation Increased gastrointestinal motility, diarrhea Alternating constipation and diarrhea Suspicion of nutritional malabsorption Frequent use of antacid medicationHave you been diagnosed with Celiac Disease,

Irritable Bowel Syndrome, Diverticulosis/Diverticulitis, or Leaky Gut Syndrome?

Category VIIIGreasy or high-fat foods cause distressLower bowel gas and/or bloating several hours after eatingBitter metallic taste in mouth, especially in the morning Burpy, fishy taste after consuming fish oils Unexplained itchy skinYellowish cast to eyesStool color alternates from clay colored to normal brownReddened skin, especially palmsDry or flaky skin and/or hairHistory of gallbladder attacks or stonesHave you had your gallbladder removed?

Category IX Acne and unhealthy skinExcessive hair lossOverall sense of bloatingBodily swelling for no reasonHormone imbalancesWeight gainPoor bowel functionExcessively foul-smelling sweat

Category XCrave sweets during the dayIrritable if meals are missedDepend on coffee to keep going/get startedGet light-headed if meals are missedEating relieves fatigueFeel shaky, jittery, or have tremorsAgitated, easily upset, nervousPoor memory, forgetful between mealsBlurred vision

Category XIFatigue after mealsCrave sweets during the dayEating sweets does not relieve cravings for sugar Must have sweets after mealsWaist girth is equal or larger than hip girthFrequent urinationIncreased thirst and appetiteDifficulty losing weight

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

Yes No

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3 Yes No

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

© 2015 Datis Kharrazian. All Rights Reserved.SMGEMAF(122215)Version 3

Category XII Cannot stay asleepCrave saltSlow starter in the morningAfternoon fatigueDizziness when standing up quicklyAfternoon headachesHeadaches with exertion or stressWeak nails

Category XIIICannot fall asleepPerspire easilyUnder a high amount of stressWeight gain when under stress Wake up tired even after 6 or more hours of sleep Excessive perspiration or perspiration with little

or no activity

Category XIVEdema and swelling in ankles and wristsMuscle crampingPoor muscle enduranceFrequent urinationFrequent thirstCrave saltAbnormal sweating from minimal activityAlteration in bowel regularityInability to hold breath for long periodsShallow, rapid breathing

Category XVTired/sluggishFeel cold―hands, feet, all overRequire excessive amounts of sleep to function properly Increase in weight even with low-calorie dietGain weight easilyDifficult, infrequent bowel movementsDepression/lack of motivationMorning headaches that wear off as the day progresses Outer third of eyebrow thinsThinning of hair on scalp, face, or genitals, or excessive hair lossDryness of skin and/or scalpMental sluggishness

Category XVIHeart palpitationsInward tremblingIncreased pulse even at restNervous and emotionalInsomnia

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 3 0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 3 0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

Yes No Yes No Yes No Yes No0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

_______ years Yes No0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

(Cont.) Night sweatsDifficulty gaining weight

Category XVII (Males Only)Urination difficulty or dribblingFrequent urinationPain inside of legs or heelsFeeling of incomplete bowel emptyingLeg twitching at night

Category XVIII (Males Only)Decreased libidoDecreased number of spontaneous morning erections Decreased fullness of erectionsDifficulty maintaining morning erectionsSpells of mental fatigueInability to concentrateEpisodes of depressionMuscle sorenessDecreased physical staminaUnexplained weight gainIncrease in fat distribution around chest and hips Sweating attacksMore emotional than in the past

Category XIX (Menstruating Females Only) PerimenopausalAlternating menstrual cycle lengthsExtended menstrual cycle (greater than 32 days) Shortened menstrual cycle (less than 24 days)Pain and cramping during periodsScanty blood flowHeavy blood flowBreast pain and swelling during mensesPelvic pain during mensesIrritable and depressed during mensesAcneFacial hair growthHair loss/thinning

Category XX (Menopausal Females Only) How many years have you been menopausal?Since menopause, do you ever have uterine bleeding?Hot flashesMental fogginessDisinterest in sexMood swingsDepressionPainful intercourseShrinking breastsFacial hair growthAcneIncreased vaginal pain, dryness, or itching

PART IIIHow many alcoholic beverages do you consume per week? How many caffeinated beverages do you consume per day? How many times do you eat out per week? How many times do you eat raw nuts or seeds per week?List the three worst foods you eat during the average week:List the three healthiest foods you eat during the average week:PART IVPlease list any medications you currently take and for what conditions:

Please list any natural supplements you currently take and for what conditions:

Rate your stress level on a scale of 1-10 during the average week:How many times do you eat fish per week?How many times do you work out per week?

© 2015 Datis Kharrazian. All Rights Reserved.SMGEMAF(122215)Version 3