Oberg & Larsen Chiropractors - Pasco, Richland, Kennewick, Washington

Health Screening Questionnaire

First Name:Last Name:
Date:
Your Occupation:
Marital Status:
Name of Spouse:

Referred By:
Date Problem Started:
Other Doctors seen for this problem:
Birth Date:
Height:
Weight:
Age:
Number of Children and Ages:
Describe current problem:

Does your present complaint involve any of the following:

Dizziness:	Pain between shoulders:	Vomiting:
Earaches:	Sinus Trouble:	Gas:
Ringing in Ears:	Sore Throat:	Indigestion:
Fainting:	Visual Disturbance:	Diarrhea:
Headaches:	Pain in abdomen:	Constipation:
Poor Appetite:	Stomach nausea:	Pain across belt line:


Shoulder/Arm Pain Right:	Left:	Calf Pain Right:	Left:
Numbness or tingling in shoulder/arm Right:	Left:	Foot Pain Right:	Left:
Hip Pain Right:	Left:	Thigh Pain Right:	Left:
Numbness or tingling in leg/foot Right:	Left:

What position, movement or activity causes this problem to feel worse?:

Describe:

What makes it feel better?:

Describe:

Have you had this problem before?:

Describe:

Do you have regular troubles with:

Headaches: Neck pain: Sinus trouble: Sore throat: Canker sores: Deafness: Dizziness: Earaches: Eyes: Lower back pain: Acid stomach: Nervous stomach: Bladder infections: Constipation: Diarrhea: Hemorrhoids: Menstrual cramping or irregularity:

Shoulder pain Right:	Left:	Hip pain Right:	Left:
Arm pain Right:	Left:	Leg pain Right:	Left:
Hand pain Right:	Left:

Have you ever had:

Cancer:	Diabetes:	Heart Trouble:
High or low blood pressure:	Kidney infections:	MS:
Ulcers:	Pneumonia:	Stroke/TIA:

When did you last visit a:

Dentist:Within 1 year
1-2 Years
When:
Family doctor:Within 1 year
1-2 Years
When:
Eye doctor:Within 1 year
1-2 Years
When:
Chiropractor:Within 1 year
1-2 Years
Who:
Last X-rays taken (when/why):
List past surgeries or serious illnesses and date:
List past broken bones and date:
List past auto accidents or serious falls and date:
List medications you take now or regularly in the past:

Are you currently pregnant:

No
Yes
Not sure

Do you currently:

Smoke:
No
Yes
Packs per day:
Use narcotics:
No
Yes
Consume alochol:
No
Yes
Frequently
Infrequently

I have the following conditions (not listed above):

If submitted for online evaluation please include your phone, city and best time to be contacted

Phone: City:
Best time to be called:
These are true answers of myself (Initial Here):

By clicking submit, I authorize the electronic transmission information to the Oberg/Larsen Chiropractic Office to be used only in accordance with federal law as described in the Health Information Privacy and Portability Act.