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Schedule Now
CALL: (954) 943-1044
Get Directions
Home
About
Dr. Jason Cheshire, DC, BCN
John Kaplon
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Testimonials
Chiropractic Care
Back Pain
Neck Pain
Sports Injury
Whiplash Treatment
Shoulder Pain
Knee Pain
Sciatica
Disc Herniation
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Back On Trac™
Knee On Trac™
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Hako-Med Electrotherapy
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Reason For Appt:
Nerve Pain
Knee Pain
Foot Pain
Shoulder Pain
Spinal Care
Allergies
Peptides Therapy
Nutritional Therapy
IV Therapy
Weight Loss
Auto Injury
If Injured, What Body Part?
Select all that apply
Neck
Back
Limbs
Wrist
Ankle
Shoulder
Scoliosis
Hip
Knee
SI Joint
Plantar Fasciitis
Side of Body
Left
Right
Bilateral
Injury Date
Please Briefly Describe Injury
Were You Seen In the Emergency Room
Yes, I was
No, I was not
If yes, where were you seen?
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Past Medical History
Have you ever had:
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HYPERTENSION
LIVER DISEASE
HYPERLIPIDEMIA
STROKE
MIGRAINES
HEARTBURN
ANEMIA
KIDNEY STONES
SKIN CANCER
PROSTATE CANCER
GASTRITIS
OSTEOARTHRITIS
CORONARY ARTERY DISEASE
DIABETES MELLITUS
SEIZURE
HYPOTHYROIDISM
EDEMA
ASTHMA
CANCER
Are You Currently On Any Medications?
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No, I am not
If you answered yes, please lest all medications (Name, Dosage, Frequency) OR Upload Image of Labels Below
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Do You Have Allergies?
Yes, I do
No, I do not
If yes, please include all allergens (Medications, Foods, Seasonal)
Surgical History:
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TONSILS
OVARY
HERNIA REPAIR
APPENDIX
UTERUS
GALL BLADDER
ORTHOPEDICS
OTHER
Family History:
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CARDIAC
CANCER
STROKE 2
OSTEOARTHRITIS
DIABETES
OTHER
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Do you have either/both of the following:
Pacemaker
Defibrillator
Do you smoke?
Yes, I do
No, I do not
If you smoke, how many cigarettes per day and how many years have you been smoking?
Do you consume alcohol?
Yes, I do
No, I do not
If you drink, how many drinks per day/week?
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Body Systems Review
Constitutional Symptoms
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Recent weight change (gain or loss)
Fatigue or general weakness
Fever
Eyes/Vision
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Eye disease or injury
Wear glasses or contact lenses
Blurred or double vision
Glaucoma
Ears Nose Mouth & Throat
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Nose bleeds
Hearing loss or ringing in ears
Sore throat, hoarseness, or voice change
Swollen glands in neck
Chronic sinus problems or rhinitis
Bleeding gums
Difficulty swallowing
Cardiovascular System
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Heart trouble
Palpitations (irregular or forceful heart beats)
Shortness of breath with walking or lying flat
Swelling of feet, ankles, or hands
Angina pectoris (chest pain, discomfort, or tightness)
Gastrointestinal System
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Loss of appetite
Nauseas or vomiting
Painful bowel movements or constipation 3
Abdominal pain
Change in bowel movements
Frequent diarrhea
Rectal bleeding or blood instool
Peptic ulcer (stomach or duodenal)
Frequent heart burn
Psychiatric Health
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Memory loss or confusion
Difficulty concentrating
Depression
Insomnia
Nervousness or anxiety
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Neurological System
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Frequent or recurring headaches
Head injury
Stroke
Numbness or tingling sensations
Light-headed or dizzy
Poor balance
Paralysis
Tremors or shaking
Convulsions or seizures
Genitourinary System
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Frequent urination
Incontinence of dribbling
Male - testicle pain or swelling
Female - pain with periods
Burning or painful urination
Kidney stones
Sexual difficulties
Female - irregular periods
Female - vaginal discharge
Denital infections or STD
Change inforce of strain when urinating
Intergumentary System & Breast Health
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Skin rash or itching
Changes in nail growth or condition
Breast pain
Breast lump
Hair loss or other scalp problems
Endocrine System
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Thyroid disease
Diabetes
Excessive thirst or urination
Heat or cold intolerance
Hematologic & Lymphatic System
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Bleeding or bruising tendency
Anemia (low red blood cell levels)
Varicose (enlarged or twisted) veins in legs
Past blood transfusions
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