Patient Application Form

1. Personal Information

First Name

Last Name

Date of Birth *

Age

Weight

Height

Gender

Male

Female

Phone *

Email *

Address

Street Address *

City *

State *

Country *

Postal code

Occupation

Employer

Marital Status

Do you have children?

Yes

No

Number of children

Emergency Contact Details

Emergency Contact Name *

Emergency Contact Phone *

Relationship of Emergency Contact

Additional Information

2. Health Goals & Concerns

What brings you to Healthy LifeCycles?

Current health issues or symptoms

How long have you been dealing with these concerns?

What do you feel has triggered or contributed to these issues?

What is your ultimate vision for your health and well-being?

What has been the biggest obstacle to achieving your health goals?

3. Chiropractic & Nervous System Health Assessment

Have You Ever Seen a Chiropractor for Spinal & Nervous System Health?

Yes, Chiropractic is a lifestyle for myself and my entire family

Yes, but only for pain relief or after an injury

No, I have never seen a chiropractor

Not regularly, but I have received chiropractic adjustments before

How frequently are you adjusted?

Multiple times throughout the week

Weekly

Monthly

Whenever I feel like it

If You Experience Any Other Symptoms That Indicate Stress on the Nervous System, please describe:

Have You Experienced Any of the Following Spinal Injuries or Conditions?

Car accident or whiplash (even minor accidents cause nervous system dysfunction)

Sports injury or repetitive strain injury (affecting spinal integrity and nervous system function)

Work-related injury (lifting, prolonged sitting, repetitive motion) (postural stress affecting spinal health)

Slips, falls, or past traumas to the spine or joints (long-term spinal dysfunction)

Disc herniation, bulging disc, or degenerative disc disease (structural issues affecting nerve function)

Scoliosis or spinal curvature issues (affects organ function, overall health and balance)

Osteoarthritis or joint degeneration (spinal misalignment accelerating joint wear)

Chronic pain condition (fibromyalgia, Ehlers-Danlos Syndrome, etc.) (linked to nervous system dysregulation)

Neuropathy or nerve-related conditions (numbness, tingling, burning sensations due to nerve interference)

If You Experienced Any Other Spinal Injuries or Conditions, please describe:

How many hours per day do you spend sitting?

Less than 2 hours

3-5 hours

6-8 hours

More than 8 hours

Do you use a standing desk or take movement breaks throughout the day?

Yes

No

Occasionally

What type of mattress do you sleep on?

Firm

Medium-firm

Soft

Not sure

What type of pillow do you use?

Orthopedic/contoured

Regular foam or down pillow

Memory foam

Other

If you use any other type of pillow, please specify:

Do you engage in regular traction or exercise for spine and nervous system health?

Yes, I traction and exercise for spine and nervous system health regularly

Occasionally, but not consistently

No, I do not have a spine and nervous system health routine

If you have recent X-rays, you can upload them below to help us better assist you.

4. Medical History

If any other diagnosed medical condition, please mention here:

If family history of any other chronic illness, please mention here:

Have you had any past surgeries or hospitalizations? If so, please provide details along with the date.

Have you had minor or significant bodily trauma

Yes

No

If you have experienced minor or significant bodily trauma, please describe here:

5. Hormonal and Reproductive Health

Hormonal imbalances

Yes

No

If you have hormonal imbalance, please describe here:

Have you had any hormone therapies?

Yes

No

If you have hormonal therapy history, please mention here:

Are you pregnant?

Yes

No

Have you had surgeries involving your reproductive organs

Yes

No

If yes, please describe the surgeries:

Hormonal Implants

Yes

No

Age at menstruation onset

Menopause Age

Irregular cycles or PMS

Yes

No

Changes in libido or energy

Yes

No

Diagnosed reproductive conditions

Yes

No

Surgeries or Implants

Yes

No

If you have had surgeries or implants, please describe:

6. Lifestyle and Habits

Daily Diet

Sleep hours per night

Do you feel rested when you wake up

Yes

No

Exercise frequency per week

Type of exercises

Do you consume alcohol?

Yes

No

On a typical drinking occasion, how many drinks do you consume?

1-2 drinks

3-4 drinks

5 or more drinks

Do you smoke cigarettes?

Yes

No, but I used to smoke

No, I've never smoked

How many cigarettes do you smoke per day?

Less than 5

11-20 (about a pack)

More than 20 (more than a pack)

Recreational drug use

Yes

No

If you have recreational drug use, please describe:

Mindfulness practices

Yes

No

If you engage in mindfulness practices, please describe:

7. Medications and Supplements

Prescription medications

Supplements, herbs, or remedies

8. Digestive and Metabolic Health

Digestive issues

Yes

No

If you have digestive issues, please describe:

Bowel movements

Bowel movements regularity

Yes

No

Bowel movements frequency

Have you experienced any recent weight changes?

Yes

No

Have you gained or lost weight?

Gained

Lost

How much weight did you gain? (kg)

How much weight did you lose? (Kg)

Over what period? (months)

9. Environmental and Toxic Exposure

Exposure to toxins

Yes

No

If you have/had exposure to toxins, please describe:

Home tested for mold

Yes

No

Pollution risks

Yes

No

If you have any pollution risk, please describe:

10. Previous Testing

Lab results to share

Yes

No

Lab Results File

11. Goal Setting

What are your top 3 health goals

Hopes for working with Healthy LifeCycles

Vision for improved life

Signature

Clear

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