Fillable www.GetWellNJ.com (732) 617-9355 Confidential Health Record

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www.GetWellNJ.com (732) 617-9355 Confidential Health Record

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Welcome To Our Oce!
Whom may we thank for referring you to our oce?
Personal Information
Name
LAST FIRST MIDDLE
Birth Date M/D/Y
/___/___
Age Sex PLEASE CHECK Male Female Social Security #
Address Apt # City State Zip
Phone # HOME CELL WORK
Email Address Occupation
Marital Status PLEASE CHECK Single Married Widowed Divorced Separated
Spouses Name
LAST FIRST # of Children
Why Upper Cervical Chiropractic?
People go to Chiropractors for a variety of reasons. Some go for symptomatic relief of pain or discomfort (
RELIEF CARE). Others are interested in having the
cause of the problem as well as the symptoms corrected and relieved (
CORRECTIVE CARE). Your doctor will weigh your needs and desires when recommending
your program of care.
PLEASE CHECK THE TYPE OF CARE THAT BEST MEETS YOUR NEEDS:
Emergency Contact
Name LAST FIRST Relationship Spouse Relative Friend
Phone #
HOME CELL WORK
Today’s Date M/D/Y
/___/___
280 US Highway 9, Morganville, NJ 07751
www.GetWellNJ.com
(732) 617-9355
Confidential Health Record
Present Health Challenge
IF YOU HAVE NO SYMPTOMS OR COMPLAINTS, AND ARE HERE FOR CHIROPRACTIC WELLNESS SERVICES, CHECK
HERE
Unwanted Health Challenge
Explain why you are here today
Has it ever occurred before? Yes No
When do you think these problems originally started?
Date of Auto Crash or Work Related Injury M/D/Y
/___/___
PLEASE CHECK ON THE DIAGRAM THE AREA OF DISCOMFORT
Relief Care is the care necessary to get rid of your symptoms
or pain, but not the cause of it. It is the same as drying a oor that
was getting wet from a leak, but not xing the leak.
Corrective Care diers from relief care in that its goal is
to get rid of the symptoms or pain while correcting the cause of the
problem. Corrective Care varies in length of time, but is more lasting.
280 US Highway 9, Morganville, NJ 07751
www.GetWellNJ.com
(732) 617-9355
PLEASE CHECK THE APPROPRIATE CIRCLE & COMPLETE BLANKS.
Body Area(s) Involved Neck Back Head Other
Mechanism of Onset Auto Work Slip/Fall Other Onset Date M/D/Y
/___/___
Current Symptoms Pain Numbness Stiness Weakness Other
Quality Burning Diuse Dull/Aching Localized Radiating Sharp Shooting
Stabbing Throbbing Tightness Tingling Other
Timing Morning Afternoon Night With Activity Constant Intermittent
What Makes it Worse?
What Makes it Better?
Level of Impairment Due to Symptoms CHECK THE APPROPRIATE LEVEL WITH 0 = NONE / 10 = EXTREME
While Resting 0 1 2 3 4 5 6 7 8 9 10
With Activity 0 1 2 3 4 5 6 7 8 9 10
Headaches Location Occipital Frontal Left Temporal Right Temporal Parietal Sinus
Quality Dull Sharp Throbbing Stabbing Aura No Aura
Types Hat Band Cluster Migraine Tension
Employment – Occupation/Job Title
Work # hours per day
Conditions Eect on Job Performance No Eect Mild Pain Moderate Pain Unable to Perform
Daily Activities – Eects of Current Condition on Performance
Bending No Eect Mild (Can do) Moderate (Limited) Severe (Unable to Perform)
Change Position (Sit-Stand) No Eect Mild (Can do) Moderate (Limited) Severe (Unable to Perform)
Climb Stairs No Eect Mild (Can do) Moderate (Limited) Severe (Unable to Perform)
Driving No Eect Mild (Can do) Moderate (Limited) Severe (Unable to Perform)
Extended Computer Use No Eect Mild (Can do) Moderate (Limited) Severe (Unable to Perform)
Household Chores / Yard Work No Eect Mild (Can do) Moderate (Limited) Severe (Unable to Perform)
Lifting No Eect Mild (Can do) Moderate (Limited) Severe (Unable to Perform)
Reading/Concentration No Eect Mild (Can do) Moderate (Limited) Severe (Unable to Perform)
Self Care (Bathe/Dress) No Eect Mild (Can do) Moderate (Limited) Severe (Unable to Perform)
Sleep No Eect Mild (Can do) Moderate (Limited) Severe (Unable to Perform)
Prolonged Sitting No Eect Mild (Can do) Moderate (Limited) Severe (Unable to Perform)
Prolonged Standing No Eect Mild (Can do) Moderate (Limited) Severe (Unable to Perform)
Walking No Eect Mild (Can do) Moderate (Limited) Severe (Unable to Perform)
Recreational Activities – PLEASE LIST ANY CURRENT RECREATIONAL ACTIVITIES AND CHECK THE EFFECTS OF CURRENT CONDITION ON PERFORMANCE
No Eect Mild (Can do) Moderate (Limited) Severe (Unable to Perform)
LIFESTYLE REVIEW
1.
On a scale of Poor, Good, Excellent please describe your lifestyle MARK POOR, GOOD OR EXCELLENT.
Diet
Exercise Sleep General Health
2. What Wellness services/products do you currently incorporate into your lifestyle?
3. What Supplements are you currently taking?
4. On a scale of 1-10 describe your stress level 1 = NONE / 10 = EXTREME Occupational Personal
5. What are your top two health goals? 1. 2. or I do not have any
6. Are you pregnant? Yes No
REVIEW OF SYSTEMS PLEASE CHECK THE ITEMS BELOW THAT APPLY TO YOU.
Nervous System
Dizziness Seizures Loss of Memory Slurred Speech Loss of Consciousness
Strokes Tremor Limb Weakness Fatigue Sleep Disturbance
Stress Numbness Headache Loss of Balance Tinnitus/Ringing in Ears
Respiration
Asthma Cough Wheezing Sputum Production Shortness of Breath
Cardiovascular
I DENY Any Symptoms Chest Pain Swelling Of Legs Low Blood Pressure Claudication (Leg Pain/Ache)
Palpitations Varicose Veins High Blood Pressure Shortness Of Breath
Gastrointestinal
Diarrhea Indigestion Abnormal Stool Vomiting Blood Weight Changes
Belching Vomiting Abdominal Pain Constipation Diculty Swallowing
Nausea Heartburn Ulcers
Psychologic
Irritability Insomnia Memory Loss Behavioral Change Bi-Polar Disorder
Anxiety Depression Mood Change Loss or Change in Appetite
Immune
Itching Anaphalaxis Food Intolerance Nasal Congestion Rash
HEALTH HISTORY
FILL OUT CAREFULLY AS THESE PROBLEMS CAN AFFECT YOUR OVERALL COURSE OF CARE.
Previous Chiropractic Care: I have not previously seen a Chiropractor OR Fill in the information BELOW.
Doctor’s Name
Date of Last Visit M/D/Y
/___/___
Current Medication(s) LIST ANY/ALL MEDICATIONS YOU ARE CURRENTLY TAKING. BE SPECIFIC.
Doctor’s Name
Illness(es) LIST ALL HEALTH CONDITIONS.
Surgery(ies) LIST ALL SURGICAL PROCEDURES. WRITE THE DATE OF THE PROCEDURE IMMEDIATELY AFTERWARD.
Injury(ies) MARK OR LIST ALL INJURIES. WRITE THE DATE OF THE INJURY IMMEDIATELY AFTERWARD.
Fall (Severe) M/D/Y
/___/___
Broken Bones M/D/Y
/___/___
Loss of Consciousness M/D/Y
/___/___
Head Injury M/D/Y
/___/___
Back/Neck Injury M/D/Y
/___/___
Motor Vehicular Crash M/D/Y
/___/___
Social History
Tobacco Do not use tobacco Smoke/Chew: #
per
Day Live with a smoker Quit smoking
Alcohol Do not use alcohol #
Drinks per Week #
Drinks per Month
An evaluation will be performed which may include spinal and physical examination, orthopedic and neurological testing, palpation, specialized
instrumentation and radiological examination (x-rays).
The statements made on this form are accurate to the best of my recollection and I knowingly allow UCC of Monmouth to examine
me for further evaluation/treatment, and understand that I am responsible for all charges incurred.
Signature Date M/D/Y
/___/___
Thank you for allowing us to serve you!
280 US Highway 9, Morganville, NJ 07751
www.GetWellNJ.com
(732) 617-9355
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www.GetWellNJ.com (732) 617-9355 Confidential Health Record

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Completed 23 February 2022

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