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Name Birthdate Age Date

Address City State Zip E-mail / Newsletter

Phone H( ) W ( ) C ( ) Height Weight Gender

Employers Name & Address Occupation


m Single m Married
Who referred you to our office? m Divorced m Widowed

Your Health Profile: Why these forms are important- As a Health & Wellness Center, our goals are to first address the issues that brought you to this
office and second, to offer you the opportunity of improved health, wellness and quality of life in the future. On a daily basis we all experience physical,
biochemical, psychological and emotional stresses that can accumulate and result in serious loss of health potential. Generally the effects are gradual
and may not even be felt until they become serious. Answering the following questions will give us a profile of the specific stresses past and present
that you face and allow us to better assess the challenges to your health potential.
HIPAA Acknowledgment of Receipt of Notice

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected
health information. These rights are more fully described in Valeo Health & Wellness Center's Notice of Privacy Practices. Valeo is permitted to revise its
Notice of Privacy Practices at any time. We will provide you with a copy of the revised Notice of Privacy Practices upon your request. Signing below
acknowledges that you have access to this notice via internet or the copy in our office for your review at any time.

Client Name: Signature: Guardian: Date:


Goals For My Care: People see health care practitioners for a variety of reasons. Some go for relief of pain, some to correct the cause of pain
and others to correct whatever the core malfunction may be. Your practitioner will weigh your needs and desires when recommending your
program of care. Please check the type of care desired so that we may be guided by your wishes.
m Relief Care - Symptomatic relief of pain or discomfort
m Corrective Care - Correcting and relieving the cause of the problem as well as the symptoms
m Comprehensive Care - Address the entire system and bring whatever is malfunctioning in the body to the highest state of health possible
m Others Goals - m Weight loss m Increased Energy m Hormone balance m Other___________________

List Health Concerns According To Their Severity: Rate it from 1 - Mild to 10 - Worst Imaginable
Health Concern Severity When did this Have you had this Did the problem begin with Constant or
episode start? before? When? an injury, trauma, or event? Intermittent?

If you are experiencing pain, is it? Sharp m Dull Ache m Stabbing m


Since the problem started, is it? Same m Improving m Worse m
Does it travel / radiate anywhere? No m Yes m Where? ______________________
What makes it better?
What makes it worse?
Do you have a family history of this or similar symptoms? No Yes, explain

Does this condition affect or interfere with your:


Work m Leisure m Sleep m Sports/Exercise m Hobbies m Mental Attitude m Other m
How so
Have you had to or felt the need to make any "positive" changes in your life due to your condition? No m Yes m
(Example: eat better, less alcohol or drugs, pray, less destructive sports, activities, etc.) If so, what?

Other Doctors seen for this condition: Diagnosis?


Medical m Chiropractor m Other m What was done?
Are you allergic or sensitive to fragrances or oils? No m Yes m
1
List all prescription drugs, over-the-counter-drugs, and all supplements you are currently taking.
Are you using any oral contraceptives or using an IUD? No m Yes m
Name of Drug or Supplement Taken for How long For What Purpose How Much

List all past accidents (auto or work), injuries, surgeries, X-rays, trauma - physical or emotional, procedures
Type Date Doctor / Hospitalization / X-Rays

Please List Your Top Three Stresses In Each Category:


Physical Stress: Ex. sitting, lifting, poor posture, orthodontics, heel lifts or jaw splint etc.
1
2
3

Bio-Chemical Stress: Ex. smoke, unhealthy foods, missed meals, don't drink enough water, drugs, pharmaceuticals, etc.
1
2
3

Psychological Stress: Ex. work, relationships, finances, self-esteem, etc.


1
2
3

The Beginning Years


Research is showing that many of the health challenges that occur later in life originated during the developmental years, some
starting at birth. Please answer the following questions to the best of your ability.
Birth to 17 Years of Age Yes No Unsure
Did you have any serious childhood illness? If yes, what?
Did you have any serious falls as a child?
Did you play youth sports? List:
Was there prolonged use of medicine such as antibiotics or an inhaler?
Were you vaccinated?
Any reactions?
Were you under regular chiropractic care? Preventative?
Comments:
Adult: 18 to Present Yes No Unsure
Are you pregnant? If yes, when due?
Do / did you drink alcohol / drugs more than socially? If yes, how many / day?
Do you play any adult sports? List:
Do you have a pacemaker?
Do you have any metal in your body? If yes, where?
2
Symptom Survey Form Date
Please rank each symptom that applies to you from 1 (minor) to 3 (severe)

Group 1
Acid foods upset 1 2 3 Gag easy 1 2 3 Appetite reduced 1 2 3 Cuts heal slowly 1 2 3

Get chilled often 1 2 3 Unable to relax, startles easily 1 2 3 Cold sweats often 1 2 3 "Nervous" stomach 1 2 3
"Lump" in throat 1 2 3 Extremities cold, clammy 1 2 3 Fever easily raised 1 2 3 Slow wound healing 1 2 3
Dry mouth-eye-nose 1 2 3 Strong light irritates 1 2 3 Neuralgia-like pains 1 2 3 1 2 3
Pulse speeds after meal 1 2 3 Urine amount reduced 1 2 3 Staring, blinks little 1 2 3 1 2 3
Keyed up-fail to calm 1 2 3 Heart pounds after retiring 1 2 3 Sour stomach frequent 1 2 3 1 2 3
Group 2
Joint stiffness after arising 1 2 3 Digestion rapid 1 2 3 "Slow starter" 1 2 3 Difficulty swallowing 1 2 3
Muscle-leg-toe cramps at Constipation, diarrhea
night 1 2 3 Vomiting frequent 1 2 3 Get "chilled" infrequently 1 2 3 alternating 1 2 3
"Butterfly" stomach, cramps 1 2 3 Hoarseness frequent 1 2 3 Perspire easily 1 2 3 Gagging reflex slow 1 2 3
Eyes blink often 1 2 3 Pulse slow; feels "irregular" 1 2 3 Eyelids swollen, 1 2 3 1 2 3
Circulation poor, puffy
sensitive to Indigestion soon after meals
Eyes or nose watery 1 2 3 Breathing irregular 1 2 3 cold 1 2 3 Always seems hungry 1 2 3
Subject to Asthma or
Feels "lightheaded" often 1 2 3 Subject to colds 1 2 3 Bronchitis 1 2 3 1 2 3
Group 3
Heart palpitates if meals Crave candy or coffee Abnormal craving for
Eat when nervous 1 2 3 missed or delayed 1 2 3 in the afternoon 1 2 3 sweets or snacks 1 2 3
Excessive appetite 1 2 3 Afternoon headaches 1 2 3 Moods of depression 1 2 3 "Blues" or melancholy 1 2 3

Hungry between meals 1 2 3 Overeating sweets upsets 1 2 3 Intense thirst 1 2 3 Awaken after few hours sleep 1 2 3
Irritable before meals 1 2 3 Get "shaky" if hungry 1 2 3 Hard to get back to sleep 1 2 3 Vision worsening over time 1 2 3

Fatigue, eating relieves 1 2 3 "Lightheaded" if meals delayed 1 2 3 Impaired Vision 1 2 3


Group 4
Hand/feet go to sleep easily
numbness 1 2 3 Get "drowsy" often 1 2 3 Bruise easily, black & blue 1 2 3 Sigh frequently, "Air hunger" 1 2 3

Tension under the breast-


Muscle cramps, worse during Noises in head, or "ringing in bone, or "feeling of tightness", Dull pain in chest or radiating
exercise; get "charley horses" 1 2 3 ears" 1 2 3 worse on exertion 1 2 3 into left arm, worse on exertion 1 2 3

Swollen ankles, worse at night 1 2 3 Tendency to anemia 1 2 3 Aware of breathing heavy 1 2 3 Frequent nose bleeds 1 2 3
Shortness of breath on Susceptible to colds
High altitude discomfort 1 2 3 exertion 1 2 3 Afternoon "yawner" 1 2 3 and / or fevers 1 2 3
Opens windows in closed
room 1 2 3
Group 5
Dizziness 1 2 3 Dry skin 1 2 3 Burning feet 1 2 3 Blurred vision 1 2 3
Itching skin and feet 1 2 3 Excessive falling hair 1 2 3 Frequent skin rashes 1 2 3 Worrier, feels insecure 1 2 3
Greasy food upset 1 2 3 Stools light-colored 1 2 3 Skin peels on foot soles 1 2 3 Use laxatives 1 2 3
Sneezing attacks 1 2 3 Bad breath (halitosis) 1 2 3 Sensitive to hot weather 1 2 3 Burning or itching anus 1 2 3
Feeling queasy;
Crave sweets 1 2 3 Coated tongue 1 2 3 Milk products cause distress 1 2 3 frequent headache over eyes 1 2 3

Dreaming, nightmare type bad Bitter, metallic taste in mouth Bowel movements painful Stools alternate from
dreams 1 2 3 in morning 1 2 3 or difficult 1 2 3 soft to watery 1 2 3
History of gallbladder attacks
or gallstones 1 2 3 Pain between shoulder blades 1 2 3
Group 6
Mucous colitis or
Loss of taste for meat 1 2 3 Coated tongue 1 2 3 Gas shortly after eating 1 2 3 "irritable bowel" 1 2 3
Lower bowel gas several Pass large amounts of foul- Burning stomach Stomach bloating after
hours after eating 1 2 3 smelling gas 1 2 3 sensations, eating relieves 1 2 3 eating 1 2 3
Indigestion 1/2 -1 hr after
eating may be up to 3-4 hours 1 2 3
3
Group 7
SECTION A
Insomnia 1 2 3 Nervousness 1 2 3 Can't gain weight 1 2 3 Intolerance to heat 1 2 3
Highly emotional 1 2 3 Flush easily 1 2 3 Night sweats 1 2 3 Thin, moist skin 1 2 3

Increased appetite without


Inward trembling 1 2 3 Heart Palpitates 1 2 3 weight gain 1 2 3 Pulse fast at rest 1 2 3
Eyelids & face twitch 1 2 3 Irritable and restless 1 2 3 Can't work under pressure 1 2 3 1 2 3
SECTION B
Headaches:
Failing memory 1 2 3 Low blood pressure 1 2 3 Increased sex drive 1 2 3 splitting or rendering 1 2 3
Decreased sugar tolerance 1 2 3
SECTION C
Dizziness 1 2 3 Headaches 1 2 3 Hot flashes 1 2 3 Increased blood pressure 1 2 3

Hair growth on face/ body- Masculine tendencies


Female 1 2 3 Sugar in urine (Not diabetes) 1 2 3 (Female) 1 2 3
Section D
Increase in weight 1 2 3 Decrease in appetite 1 2 3 Fatigue easily 1 2 3 Ringing in ears 1 2 3
Sleepy during day 1 2 3 Sensitive to cold 1 2 3 Dry or scaly skin 1 2 3 Constipation 1 2 3
Headaches upon arising
Mental sluggishness 1 2 3 Hair coarse, falls out 1 2 3 wear off during day 1 2 3 Slow pulse, below 65 1 2 3
Frequency of urination 1 2 3 Impaired hearing 1 2 3 Reduced initiative 1 2 3
Section E
Abnormal thirst 1 2 3 Bloating of abdomen 1 2 3 Weight gain around hips/waist 1 2 3 Sex drive reduced or lacking 1 2 3
Lack of menstrual function
Tendency to ulcers, colitis 1 2 3 Increased sugar tolerance 1 2 3 Menstrual disorders (Female) 1 2 3 (Young girls) 1 2 3
Section F
Weakness, dizziness 1 2 3 Chronic fatigue 1 2 3 Low blood pressure 1 2 3 Nails wear, ridged 1 2 3
Tendency to hives 1 2 3 Arthritic tendencies 1 2 3 Perspiration increase 1 2 3 Bowel disorders 1 2 3
Poor circulation 1 2 3 Swollen ankles 1 2 3 Crave salt 1 2 3 Brown spot/ bronzing skin 1 2 3
Weakness after colds, Exhaustion-muscular &
Allergies-tendency to asthma 1 2 3 influenza 1 2 3 nervous 1 2 3 Respiratory disorder 1 2 3
Gender Specific
Female Only
Very easily fatigued 1 2 3 Premenstrual tension 1 2 3 Painful menstruation 1 2 3 Painful breasts 1 2 3
Depression feelings Menstruation excessive and Hysterectomy/ovaries
before menstruation 1 2 3 Depression of long standing 1 2 3 prolonged 1 2 3 removed 1 2 3
Menstruate too frequently 1 2 3 Vaginal discharge 1 2 3 Menopausal hot flashes 1 2 3 Menses scanty or missed 1 2 3
Acne, worse at menses 1 2 3 Mood Swings 1 2 3 Mental Tension 1 2 3
Age of first period Birth Control Type # of Abortions # of Live Births
# of days of period Length of cycle # of Pregnancies # of Miscarriages
Male Only
Prostate trouble 1 2 3 Urination difficult or dribbling 1 2 3 Night urination frequent 1 2 3 Depression / Mental Tension 1 2 3
Feeling of incomplete bowel
Pain on inside of legs or heels 1 2 3 evacuation 1 2 3 Lack of energy 1 2 3 Migrating aches and pains 1 2 3
Tire too easily 1 2 3 Avoids activity 1 2 3 Leg nervousness at night 1 2 3 Diminished sex drive 1 2 3
Group 8
Apprehension 1 2 3 Headaches 1 2 3 Irritability / Mood Swings 1 2 3 Insomnia 1 2 3
Morbid fears 1 2 3 Anxiety 1 2 3 Never seems to get well 1 2 3 Anorexia 1 2 3
Forgetfulness 1 2 3 Indigestion 1 2 3 Poor appetite 1 2 3 Craving for sweets 1 2 3
Muscular soreness 1 2 3 Loose joints 1 2 3 Noise sensitivity 1 2 3 Weakness 1 2 3
Fatigue 1 2 3 Nervousness 1 2 3 Skin sensitive to touch 1 2 3 Tendency toward hives 1 2 3

Inability to concentrate; Frequent stuffy nose; sinus


confusion 1 2 3 infections 1 2 3 Allergy to some foods 1 2 3 Depression; feelings of dread 1 2 3
Acoustic hallucinations 1 2 3 Cry without reason 1 2 3 Hair is coarse and/or thinning 1 2 3 Chronic Infections 1 2 3
Group 9
Impaired Vision 1 2 3 Eye Pain / Strain 1 2 3 Glaucoma 1 2 3 Glasses / Contacts 1 2 3
Tearing / Dryness 1 2 3 Impaired Hearing 1 2 3 Ear Ringing 1 2 3 Earaches 1 2 3
Headaches 1 2 3 Sinus Problems 1 2 3 Nose Bleeds 1 2 3 Frequent Sore Throats 1 2 3
Teeth Grinding 1 2 3 TMJ / Jaw Problems 1 2 3 Hay Fever 1 2 3 Menopausal Syndrome 1 2 3
Difficulty Conceiving 1 2 3
4
Health History Information

Body Area Rare Mild Moderate Severe


Neck
Upper Back
Lower Back
Chest
Abdomen
Arms
Hands
Quads
Hamstrings
Calves
Feet

Please mark with an “X” any disorder that you have experienced in the last 5 years
Cardiovascular Nervous Skeletal Muscles
Heart Disease Chronic pain / Sciatica Osteoporosis Muscular tension

High BP Shingles / herpes Vertebral disc disorders Spasms, cramps


Blood Vessel Disorder Spinal cord injuries Arthritis (any type) Fibromyalgia
Varicose Veins MS / Parkinson’s Sprains / strains Muscular dystrophy
Bleeding Disorder Cerebral Palsy Tendonitis / Bursitis Jaw pain / TMJ
Blood Clots Numbness / tingling Carpel tunnel Joint stiffness/swelling
Scoliosis
Stroke Epilepsy

Cold Hands / Feet Fatigue or chronic fatigue

Other Notes
Any Infections
AIDS

Contagious Rashes
Asthma / Sinus
Dizziness
Ear Ringing
Headache
Digestive Discomfort
Diabetes
Cancer
PMS / Menopause
Warts