Dr. Eric Duncan

Welcome to the Duncan Chiropractic Group. As a new patient you will find that we are able to help you with all of your Chiropractor needs. We are able to treat a number of different ailments including, but not limited to, auto injuries, back pain, blood pressure problems, fatigue/lack of energy, migraine headaches and spinal decompression therapy. For a full listing, please see our Services page. To help us establish you with our practice, please provide us with your complete health history. This information will allow us to make your first visit more beneficial. At the Duncan Chiropractic Group it is our mission to improve the function of each patient.

• Patient Information
Name:
E-mail address:
Home Phone:
Work Phone:
Best time & place to reach you:
Address:
City:
State:
Zip:
Age:	Sex: F M
Birthdate:	MM/DD/YYYY
Status:	Single   Married   Widowed   Divorced
Patient SSN:
Occupation:
Employer:
• Spouse’s Information
Spouse’s Name:
Spouse’s Birthdate:	MM/DD/YYYY
Spouse’s Occupation:
Spouse’s Employer:
Children (Age):
• In Case of Emergency
Name:
Relationship:
Home Phone:
Work Phone:
Whom may we thank for referring you?
• Accident Information
Is condition due to an accident?   Y   N   Date:
Type of accident?	Auto Work Home Other
To whom have you made a report of your accident?
Car Insurance Employer Worker Comp. Other
Attorney Name: (If Applicable)
• Patient Condition
Reason for Visit:
When did your symptoms appear?
Is this condition getting progressively worse? Y N Not Sure
According to the diagram on the right, where do you continue to have pain, numbness, or tingling? Rate the severity of your pain on a scale from 1 (least pain) to 10 (most pain): Type of pain: Sharp Dull Throbbing Numbness Aching Shooting Burning Tingling Cramps Stiffness Swelling Other
How often do you have this pain? - Is it:
Constant Comes and Goes Present While Resting Present only with Motion
Does it interfere with your:
Work Sleep Daily Routine Recreation
What else does it prevent you from doing?
Activities that are painful to perform:
Sitting Standing Walking Bending Laying Down
• Medication: (Rx / Condition)
• Supplements/Vitamins/Herbs:
• Allergies:
• Previous Injuries/Surgeries:
• Previous Chiropractic Care:
Condition:
Doctor:
Results:
Reason Stopped Going:
What did you like about care:
What did you dislike about care:
• Heath History
What treatment have you already received for your condition:
Medications Surgery Physical Therapy Chiropractic Acupuncture Massage None Other:
Name and location of other doctor(s) who have treated you for you condition:
Date of Last:
Physical Exam: Spinal X-Ray: Blood Test: Spinal Exam: Chest X-Ray: Urine Test: MRI, CT-Scan, Bone Scan:   Other:
Place a mark on "Y" or "N" to indicate if you have had any of the following:
Y N     Y N     Y N     Y N AIDS/HIV DIABETES LIVER DISEASE RHEUMATIC ARTH. ALCOHOLISM EMPHYSEMA MEASLES RHUEMATIC FEVER ALLERGY SHOTS EPILEPSY MIGRAINES SCARLET FEVER ANEMIA FRACTURES MISCARRIAGE STROKE ANOREXIA GLAUCOMA MONO SUICIDE ATTEMPT APPENDICITIS GOITER MULTI. SCLEROSIS THYROID PROBLEMS ARTHRITIS GONORRHEA MUMPS TONSILITIS ASTHMA GOUT OSTEOPOROSIS TUBERCULOSIS BLEEDING HEART DISEASE PACEMAKER TUMORS BREAST LUMP HEPATITIS PINCHED NERVE TYPHOID FEVER BRONCHITIS HERNIA PARKINSON'S ULCERS BULIMIA HERNIATED DISC PNEUMONIA VAGINAL INFECTION CANCER HERPES POLIO VENEREAL DISEASES CATARACTS HIGH CHOLESTEROL PROSTATE WHOOPING COUGH CHICKEN POX KIDNEY DISEASE PSYCHIATRIC CARE OTHER:
• Exercise
None Light Moderate Heavy # of times/weeks:
• Work Activity
Sitting Standing Light Labor Heavy Labor Safety Devices Utilized:
• Habits
Smoking - Packs/Day: Alcohol - Drinks/Week: Coffee / Caffeine - Cups/Day: High Stress Level - Reason: Other
• Past Traumas or Conditions:
Was Your Birth Difficult?  Date: Childhood Ailments:  Date: Any Car Accidents or Whiplash:  Date: Falls: Date: Head Injuries: Date: Broken Bones: Date: Dislocation: Date: Any Reoccurring Infection: Date: Any Family History of Diseases or conditions? Date: Other: Date:
• Pregnancy:
Are you Pregnant? Y N Due Date: