GEORGE SIEGFRIED, D.C.
Chiropractic Physician
SINCE 1983
Dunn Chiropractic Clinic Johns Landing Clinic
301 NE Dunn Place 6501 SW Macadam Ave.
McMinnville, OR 97128 Portland, OR 97239
Since 1915 Since 2005
Phone 503-472-6550 Phone 503-977-0055
Fax 503-472-1039 Fax 503-977-0062
NAME ____________________________ DATE ______________________
ADDRESS________________________ CITY________________ ZIP ______
PHONE __________________ WORK # ______________ CELL ___________
BIRTHDATE __________AGE ____OCCUPATION ______________________
EMAIL ADDRESS_________________________________________________
WOULD YOU LIKE TO BE ON DR. SIEGFRIED’S HEALTH NOTES EMAIL LIST? Yes / No
Who referred you to the clinic? _____________________________________
What brings you to the clinic today? _________________________________
When did this start? ________________________________________________
Have you ever been to a Chiropractor? ________ Who? _________________
For what condition? _____________________ When? _______________
Were x-rays or MRIs taken? Yes / No When? ________ Where? _______
Have you ever had Non-Surgical Disc Decompression for a Bulging, Degenerating or Herniated Disc? Yes / No
Have you ever had a Bilateral Nasal Specific Treatment? Yes / No
Have you ever had a concussion, broken nose or hit in the head? Yes / No
Have you ever had this complaint before? Yes / No
What other doctors have you seen for this condition? __________________
How does this affect your daily life? _________________________________
Have you lost any work days? Yes / No How many? _____________________
Are you taking any medications? Yes / No If so, for what condition? ________________________________________________________________
Are you taking any vitamins/herbs, etc.? _____________________________
Are you under care for any other conditions? _________________________
Have you had any surgeries? Yes / No For what? _______________________
Any broken bones? _______________________________________________
Have you had any root canals in your teeth? Yes / No
Do you have any mercury fillings? Yes / No
Are you wearing: Heel Lifts? Yes / No Arch Supports? Yes / No
What kind of water do you drink? Tap ___ Bottled ___ Spring ___ Distilled ___ Filtered ___
Family History:
______ Arthritis ______ Cancer ______ Diabetes
______ Heart Disease ______ Back Problems ______ Scoliosis
Any others please list: _____________________________________________________________________
What is your health goal regarding your complaint?
______ Patch Care = pain relief
______ Fix Care = trying to get your body as near to normal as possible
Put a circle around the appropriate number on this scale:
(No Pain) 1 2 3 4 5 6 7 8 9 10 (Worst Pain Imaginable)
Signature: _____________________________________________ Date: ___________________________
Signature of parent or guardian if giving permission for a treatment of a minor:
________________________________________________________
Emergency Contact: ___________________________________ Phone: _________________________