Performance Health Center
Performance Health Center
6268 S. Rainbow Blvd., Suite 105
Las Vegas, NV 89118
Phone: (702) 966-5920
Email: performancehealthcenterlv@
_________________________________________________________________________________________________
Patient Information
Name: __________________________________________________________________________ Date: __________________________
Last First Middle Initial
Address: ________________________________________________________________________________________________________
Street Address Apt # City State Zip Code
Home Phone: ( )_______________________________________ Cell: ( )____________________________________________
DOB: ____/____/____ SSN #:_____-____-_____ Email:_________________________________________________________________
Marital Status: Single ( ) Married ( ) Divorced ( ) Widowed ( ) Separated ( )
Occupation: ________________________________________ Employer: ____________________________________________________
Employer Address: _______________________________________________________________________________________________
Street Address City State Zip Code
Emergency Contact: _____________________________ Phone: ( )______________________ Relationship:_____________________
Whom may we thank for referring you to our office? ____________________________________________________________________
Current Health Conditions
What is your primary health complaint(s)?_____________________________________________________________________________
Date symptoms first appeared? ___/___/___ Describe any related accident or injury: ___________________________________________
_______________________________________________________________________________________________________________
What aggravates your symptoms? ___________________________________________________________________________________
What alleviates your symptoms? ____________________________________________________________________________________
Have you tried anything to get rid of this problem that did NOT work? Yes ( ) No ( )
If yes, please explain. _____________________________________________________________________________________________
What other health practitioners have you consulted for this/these complaints? _________________________________________________
What daily habits do you have that could make this problem worse? ________________________________________________________
When this problem is at its worst, does it interfere with your: Work? ( ) Family Life? ( ) Recreation? ( )
List of current medications and/or supplements: ________________________________________________________________________
_______________________________________________________________________________________________________________
Please mark the areas of pain on the figures below.
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Type of Pain:
Sharp______ Dull______ Aching______ Burn______ Throb______ Numb______ Other______
Does the pain radiate? Yes______ No______ Where to?_________________________________
How would you rate your pain? 0—1—2—3—4—5—6—7—8—9—10
No pain Unbearable
Medical History
Past Surgeries/Operations:___________________________________________________________________ ______________________
Major accidents or falls since birth:____________________________________________________________ ______________________
Hospitalizations (other than above):__________________________________________________________________________________
Are you currently under the care of a medical physician? If yes, for what condition?___________________________________________
Please list the physicians’ name, phone number, and the approximate last date of treatment:______________________________________
_______________________________________________________________________________________________________________
Have you had previous Chiropractic care? Yes ( ) No ( ) Please list doctor’s name and approximate date of last visit:___________________________________________________________________________________________________________
Are you currently under the care of any other alternative healthcare practitioners?
Acupuncturist______ Massage therapist______ Nutritionist______ Pilates______ Other_____________
Please check any of the following you have had/been diagnosed with in the past:
____Pneumonia ____Measles ____Influenza ____Rheumatic fever ____AIDS/HIV ____Anemia
____Mumps ____Pleurisy ____Polio ____Small pox ____Arthritis ____Eczema/Psoriasis
____Tuberculosis ____Cancer ____Heart Dis. ____Thyroid Dis. ____Whooping cough
Please check any of the following you have had in the past six months:
Musculoskeletal Gastrointestinal Eyes/Ears/Nose/Throat
____Low back pain ____Poor Appetite/Underweight ____Vision problems
____Pain between shoulders ____Excessive Appetite/Overweight ____Dental problems
____Neck pain ____Unexplained weight loss ____Earache/Infections
____Shoulder/arm/wrist pain ____Frequent nausea ____Difficulty hearing
____Hip/knee/ankle pain ____Vomiting ____Ringing in the ears
____Joint pain/stiffness ____Diarrhea ____Cold/Flu
____Difficulty walking ____Constipation ____Sinus problems
____Jaw/Head pain ____Hemorrhoids ____Sore throat
Nervous System ____Liver problems Cardiovascular
____Cold/tingling extremities ____Gall bladder problems ____Chest pain
____Numbness/Loss of sensation ____Abdominal cramps ____Shortness of breath
____Dizziness ____Gas/Bloating after meals ____High blood pressure
____Fainting ____Heartburn ____Irregular heartbeat
____Forgetfulness ____Excessive thirst ____Heart problems
____Depression ____Colitis/Crohn’s/IBS ____Lung symptoms/congestion
____Seizures Genitourinary ____Varicose veins
____Paralysis ____Painful/Excessive urination ____Ankle swelling
____Nervousness ____Discolored urine ____Stroke
____Stress ____Bladder infections Female Only
General ____Urinary leakage ____Menstrual cramps
____Fatigue Male only ____Irregular/absent periods
____Loss of sleep ____Prostate Dysfunction ____Vaginal infection/pain
____Unexplained fevers ____Loss of libido ____PMS
____Headaches ____Sexual dysfunction ____Loss of libido
____Allergies ____Menopausal symptoms
____Pain at night ____Breast pain
____Uterine/Ovarian fibroids
Are you pregnant? Yes____ No____
Is there anything else you would like the doctor to know regarding your health? _________________________________________
_________________________________________________________________________________________________________
Consent to Treatment
I, voluntarily consent to receive medical and health care services that may include diagnostic procedures, examinations, and treatment.
Financial Responsibility and Assignment of Benefits
I agree to pay all charges for medical and health care services not covered by my insurance company.
Missed Appointments
We respect our patient’s time and try to manage appointments as efficiently as possible. For this reason, we ask that you please contact us at least 24 hours prior to your scheduled appointment time for any changes that need to be made. Failure to do so may result in a service charge of $25 to your account.
I certify that I have read this form and understand its contents.
______________________________________ ____________________________________ ____________________
Print Name Signature Date
HIPAA: Notice of Privacy Practices
I have read and understand the HIPAA Privacy Act. **HIPAA information is on laminated sheet on the clipboard**
______________________________________ ____________________________________ ____________________
Print Name Signature Date
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