Chiropractic Centers of Virginia

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Symptom Information

What date did your symptoms begin?
Month Day Year Have you ever had these symptoms before? Yes No Please choose one.
When
How did this happen?
Is this injury work or auto accident related? Yes No
Are your arms or legs involved? Yes No
Please describe your chief complaint
What makes it feel better?
What makes it feel worse?
Please list all the medications prescribed to you within the last year
What kind of activities do you participate in during your free time?

Have you ever had or are you having problems with any of the following?

Headaches Yes No
If yes, how often and when
Dizziness Yes No
If yes, how often and when
Sinus Pain Yes No
If yes, how often and when
Neck Pain Yes No
If yes, how often and when
Upper back Pain Yes No
If yes, how often and when
Mid-back Pain Yes No
If yes, how often and when
Low back Pain Yes No
If yes, how often and when
Shoulder Pain Yes No
If yes, how often and when
Chest Pain Yes No
If yes, how often and when
Heart Yes No
If yes, how often and when
Stomach Yes No
If yes, how often and when
Bladder Yes No
If yes, how often and when
Liver Yes No
If yes, how often and when
Kidney Yes No
If yes, how often and when
Colon Yes No
If yes, how often and when
Hip Yes No
If yes, how often and when
Circulation Yes No
If yes, how often and when
Prostate Yes No
If yes, how often and when
Breast Yes No
If yes, how often and when
Have you ever been in an accident? Yes No If yes. Please explain.
Have you ever been hospitalized or had any surgery? Yes No If yes. Please explain.
Have you ever had measles, mumps, rheumatic fever, sexually transmitted
disease or any other type of infection? Yes No If yes. Please explain.
Have you or your family ever had cancer? Yes No If yes. Please explain.
Have you or a family member ever been diagnosed with diabetes? Yes No If yes. Please explain.
Has any family member ever had neck, back, or spinal problems? Yes No If yes. Please explain.
Do you drink alcohol, smoke cigarettes, or ever use any recreational drugs? Yes No If yes. Please explain.
If female, any possibility of currently being pregnant? Yes No If yes. Please explain.

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