Cleveland Chiropractic & Wellness Center Dr. Emily Arnold-Wheat 2460 Fairmount Blvd

Cleveland Chiropractic & Wellness Center

Dr. Emily Arnold-Wheat

2460 Fairmount Blvd.

The Heights Medical Building, Unit B

Cleveland Hts., OH 44106
Patient Title:

___ Mr. ___ Mrs. ___ Ms. ___ Miss ___ Dr. ___ Prof. ___ Rev.

First Name________________________ Date of Birth ____/_____/_____

Last Name________________________ Gender ___ Male ___ Female

Address___________________________ SSN: ____- ____- _______

City________________________________ Driver License # ___________

State_____ Zip Code ________ Marital Status: ___Single ___ Married ___ Other

Primary Phone_____________________

Mobile Phone______________________ Emergency Contact: _______________

Email_______________________________ Relationship to Patient: _____________

Primary Phone: ___________________

By providing my email address, I authorize my doctor to contact me via email.
Employment Status:

_____ Employed ____ FT/PT Student ____ Retired ____ Unemployed

Race:

______Caucasian _____ African American

______Hispanic or Latino _____Asian

______American Indian or Alaska Native _____Multi-Racial

______ Native Hawaiian or Other Pacific Islander _____Other

______ I choose not to specify

Preferred Language: ___________________

How did you hear about us: ______________________


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Cleveland Chiropractic & Wellness Center

Dr. Emily Arnold-Wheat

2460 Fairmount Blvd.

The Heights Medical Building, Unit B

Cleveland Hts., OH 44106

Medical History

List current medications and vitamins including frequency and dosage, if known. If there are no current medications or vitamins being taken, check here: ______

Medication/Vitamins	Why are you taking this (ie 1 tablet/5mg)	Frequency (ie 2 times/day)	Start Date

Smoking and Allergy History

Do you currently smoke tobacco of any kind?

_____Yes ____No If yes, how many cigarettes per day? _____

Do you have any allergies?

____ Yes ____ No If yes, please list any known allergies: ________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________

Social History

Employer’s Name: _____________________

Job Title and Description: ______________________________________________________________________
What do you do most of the day at work?

____ Sit ___Stand ___Light Labor ___Heavy Labor ___ Other

How often do you consume alcohol or use recreational drugs? _________

What kind? _________________________________________________

Cleveland Chiropractic & Wellness Center

Dr. Emily Arnold-Wheat

2460 Fairmount Blvd.

The Heights Medical Building, Unit B

Cleveland Hts., OH 44106

Health Review

How many hours of sleep are you getting per night? Is your sleep routine?

___Less than 5 ___6-8 ___8-10 ___10 or more
Do you have trouble falling to sleep? Staying asleep?
How would you rate your sleep on the following scale?

No/Poor Sleep 1 2 3 4 5 6 7 8 9 10 Fully Rested
How many days a week do you exercise for 30 minutes or more? ____ Days
How would you rate your stress level?

Low 1 2 3 4 5 6 7 8 9 10 High
List your major stressors: _____________________________________________________________________________
What are your expectations for care at Cleveland Chiropractic and Wellness Center? _____________________________________________________________________________

_____________________________________________________________________________

Are you currently under the care of any doctor for your condition?

___ Yes, Dr. __________________________

___No
Have you seen a chiropractor in the past?

___Yes

___No

Date of last visit____/____/_____

Name of previous Chiropractor______________

Were you satisfied with your care?

___Yes

___No

Why? __________________________________

Injuries: (List date next to injury)

___ Back injury

___ Broken bones

___ Disability (ies)

___ Fall (severe)

___ Fracture

___ Head injury

___ Industrial accident

___ Joint injury

___ Laceration (severe)

___ Motor vehicle accident

___ Soft tissue injury

___Stroke

___ Other: _______

Cleveland Chiropractic & Wellness Center

Dr. Emily Arnold-Wheat

2460 Fairmount Blvd.

The Heights Medical Building, Unit B

Cleveland Hts., OH 44106
What is your chief complaint today?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Have you had any serious illnesses?_______________________________________

Do you have any food allergies?__________________________________________

Please list all surgeries you have had: ____________________________________________________________________________________________________________________________________________

On a scale of 1 to 10, what is your present energy level?

Worst 0 1 2 3 4 5 6 7 8 9 10 Best

Bowel Movements

Number per day?______ Number per week?______ Well formed?______

Hard?______ Small marble size?______ Runny/loose?______

Please check any of the following you have currently or have had in the past:

___Abnormal Heart Problems ___Goiter ___Painful Menstruation

___HIV/AIDS ___Gout ___Painful Intercourse

___Anemia ___Heart Murmur ___Pneumonia

___Aneurysm ___Hepatitis ___Sinus Problems

___Appendicitis ___Hernia ___Skin Infections

___Arteriosclerosis ___Herpes ___Stroke

___Arthritis ___Hypersensitivity ___Tuberculosis

___Asthma

___Auto-Immune Disease ___Influenza ___Venereal Infection

___Cancer ___Excessive Bleeding ___Alzheimer’s

___Chest Pains ___Light Headedness ___Cerebral Palsy

___Circulatory Problems ___Lupus ___Chicken Pox/Shingles

___Cold Sores ___Malignancies ___Colitis

___Diabetes ___Measles ___CRPS (RSD)

___Dizziness ___Migraines ___CVA (Stroke)

___ Disc Problems ___Miscarriage ___Cystic Kidney Disease

___Emphysema ___Multiple Sclerosis ___Depression

___Epilepsy ___Mumps ___Eczema

___Eye Pains ___Nervous Problems ___Fibromyalgia

___Fever Blisters

___Female Hormonal issues ___Night-Time Urination ___Heart Disease

___Frequent Colds ___Nosebleeds ___High Blood Pressure

___Frequent Urination ___Psychiatric Problems ___Liver Disease

___Lupus Erythema ___Multiple Sclerosis ___Parkinson Disease

___Psoriasis ___Psychiatric Condition ___Scoliosis

___Unspecified Pleural Effusion ___Seizures ___Shingles

___STD’s (unspecified) ___Suicide Attempts ___Thyroid Problems

___Vertigo ___Hypertension ___Other:______________

Disclaimer

Your nutritional-wellness care plan in this office is not designed to replace, negate or cancel out the medical care plan prescribed by your primary care physician. Instead, it is designed as an alternative health care adjunct to incorporate food, supplements, vitamins, lifestyle changes, and herbal regimens to assist you in achieving your health and wellness goals. Nutritional counseling, vitamin recommendations, nutritional advice and the adjunctive schedule of nutrition is provided solely to upgrade the quality of foods in the patient’s diet in order to supply good nutrition supporting the physiological and bio-mechanical processes of the human body. Your health is ultimately your responsibility and therefore our treatment regimens are highly suggested plans yielding highly favorable outcomes, depending upon your full compliance and adherence. The wellness plans are uniquely designed for your individual case. Our method of wellness care is supported by the results of clinical and cutting edge scientific research. Therefore, the products recommended in your health and wellness plan have not been regulated by the FDA as they are not classified as drugs.

Patient signature:_________________________ Date:____________