D Dr. Thomas Campbell D.C.

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Dr. Christopher B. Kessler D.C., M.S., C.C.E.P.
. 1300 Iroquois Drive Suite 270
Naperville, IL 60563

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Full Name:____________________________________________ TodaysuDate_______________________________
S.S.# _______________________________________ Age _______________ sDate of Birth: ____________________
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Address______________________________________________________________________________________________
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City _______________________State: ____________Zip _____________ Height ___________ Weight __________
Occupation ___________________________________Where Employed _____________________________
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Cell Phone _______________________________ Home __________________________ Work __________________
I prefer to receive calls at (circle) Home/Work/Cell a
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I am (circle) Under Age 18/Single/Married/Divorced/Widowed/Separated
Emergency Contact: ___________________________Emergency Contact d Phone No.: _________________
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Primary Care Physician_______________________________ Practice Location: ________________________
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Your Email address_________________________________________________________________________________
How did you hear about our clinic ?______________________________________________________________
An understanding of your health history will help us to D determine appropriate care
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I. Please describe your current complaint. In other words, . what brought you to our
clinic?
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________________________________________________________________________________________________
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________________________________________________________________________________________________
II. r
Did the pain begin after an accident or injury? __________________________________________
III. i
Approximately when did the pain begin? ________________________________________________
IV. On a scale from 0 to 10, with 0 being the least intense, s 10 being the most intense, on
what level would you rate your pain when it is at itst worst? _________________
V. o
How would you describe the quality of the pain? ______________________
VI. p
What helps you with the pain? ___________________________________________________________
VII. h
What makes the pain worse? _____________________________________________________________
VIII. Are there any associated symptoms with your current e complaint that you are
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aware of? ___________________________________________________________________________________
IX. What aspect of your daily activities does your pain interfere with the most?
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________________________________________________________________________________________________
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________________________________________________________________________________________________
X. Is there a previous history of this complaint before? Yes/No If yes, please
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describe______________________________________________________________________________________
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________________________________________________________________________________________________
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Review of Systems: s
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1. Do you have skin, hair, or nail problems? Yes/No __________________________________________
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2. Do you have mouth and/or throat problems? Yes/No______________________________________
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3. Do you have nose and/or sinus problems? Yes/No_________________________________________
4. Do you have ear problems? Yes/No__________________________________________________________
5. Do you have eye problems? Yes/No__________________________________________________________
6. Do you have chest or lung (breathing problems)? Yes/No_________________________________
7. Do you smoke? Yes/No Cigarettes per day___________ How Long? _______________________
8. Do you have heart and/or blood vessel problems? Yes/No _______________________________
9. Do you have blood or lymph node problems? Yes/No_____________________________________
10. Do you have digestive problems? Yes/No___________________________________________________
11. Do you have genital problems (e.g. prostate, testicular, vaginal)? Yes/No_______________
12. Do you have urinary, bladder, or kidney problems? Yes/No_______________________________

13. FEMALES Have you had menstrual problems? Yes/No__________________________________

Have you ever taken birth control pills? Yes/No For how long? ______________
Is there any chance that you care currently pregnant? Yes/No_________________
Do you have any breast problems? Yes/No ______________________________________
14. Do you have any nervous system diseases and/or mental health problems? Yes/No
____________________________________________________________________________________________________
15. Do you have any gland and/or hormone problems? Yes/No_______________________________
16. Do you have allergy or immunity problems? Yes/No_______________________________________
17. Do you have any muscle, tendon, or ligament problems? Yes/No_________________________
18. Do you have any bone or joint diseases? Yes/No___________________________________________

Family History:
19. Are there any diseases or conditions that are common among your family members?
Yes/No________________________________________________________________________________________

Past History:
20. List any diseases that you have had in the past, including childhood diseases:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
21. Tell us if you have ever been diagnosed as having a particular condition, such as
diabetes, cancer, AIDS, etc: ________________________________________________________________________

22. Have you suffered any physical injuries, such as falls or blows, automobile accidents,
whiplash, concussion or head injury, lacerations, sprains, strains, dislocations, broken or
cracked bones? Yes/No If yes, describe accident including date of accident
________________________________________________________________________________________________________
________________________________________________________________________________________________________
23. List any surgeries you have had:
_________________________________________________________Date:_________________________________________
_________________________________________________________Date:_________________________________________
_________________________________________________________Date:_________________________________________
_________________________________________________________Date:_________________________________________
24. Have you ever been hospitalized for any reason other than surgery?
Yes/No_______________________________________________________________________________________________
25. Please list all medications that you are currently taking or take on an occasional basis:
________________________________________________________________________________________________________
26. Have you ever had cancer? Yes/No If yes describe? ______________________________________
Social History:
27. In what position do you usually sleep? _______________________________________________________
28. Do you exercise on a regular basis? Yes/No activities? ___________________________________
29. Your diet is: Balanced Fair Poor Excessive Restricted
30. Do you use: Caffeine Tobacco Nicotine Recreational Drugs Alcohol

31. Please describe your work:

Type: Professional Physical Labor Driver Clerical Factory Homemaker
Physical Demands: Heavy Moderate Mild Sedentary
Stress Level: High Medium Low

Additional History
33. If there is any information about your health history that was not requested, please fill
in below______________________________________________________________________________________________
35. Have you ever seen a Chiropractor before? Yes/No If yes how long ago? ______________
36. Have you ever seen a physical therapist before? Yes/No If yes how long ago?__________
37. What are you hoping to achieve from care in our office (please check all that apply)
relief care corrective care wellness/preventative care

Do you have health insurance? _____________ Yes ____________ No

Please have your health insurance card and drivers license ready so they can be copied
for the clinics records.

CONSENT FOR TREATMENT

Assignment & Release-By signing below, I authorize Victory Rehab, LLC to release
medical records required by my insurance company(s). I authorize my insurance
company(s) to pay benefits directly to Victory Rehab, LLC and I agree that a reproduced
copy of this authorization will be as valid as the original. I understand that I am
responsible for any amount not covered by my insurance, or amount for a patient for
which I am the guarantor. I agree that I will be responsible for any collection agency or
attorney fees incurred. I understand that by signing below, I am giving written consent for
the use and disclosure of protected health information for treatment, payment, and health
care operations.

By signing below, I give my consent for examination and the performance of any tests or
procedures needed. If patient is a minor, by signing I give consent for examination, tests
and procedures for the above minor patient.

Signed: _________________________________________________________________ Date: _____________________