Chiropractic New Patient Form

Step 1 of 4

25%

Patient Information:

Date(Required)

MM slash DD slash YYYY

SSN(Required)

Birthday(Required)

MM slash DD slash YYYY

First Name(Required)

Middle Name(Required)

Last Name(Required)

Sex(Required)

Male

Female

Height(Required)

Weight(Required)

Married/Civil Union(Required)

Spouse Name(Required)

# of Children(Required)

Address(Required)

City(Required)

State(Required)

Zip(Required)

Emergency Contact(Required)

Emergency Relation(Required)

Emergency Phone(Required)

Email(Required)

Employer Information:

Employed(Required)

Employer Name(Required)

Employer Address(Required)

Employer City(Required)

Employer State(Required)

Employer Zip(Required)

Occupation(Required)

Work Supervisor(Required)

Supervisor #(Required)

Work Duties

Reason for this Visit:

Describe the reason for this visit?(Required)

When did this concern begin?(Required)

Has this concern:(Required)

Gotten Worse

Stayed Constant

Come and Gone

Does this concern interfer with:(Required)

Work

Sleep

Daily Routine

Other Activites

Briefly Explain:(Required)

Has this concern occured before?

Yes

Briefly Explain:(Required)

Have you seen other doctor's for this concern?(Required)

Yes

Doctor's Name(Required)

Type of treatment:(Required)

Complaint Information:

Injury Occurred(Required)

Work

Automobile

Third-Party

Other

Injury Date(Required)

MM slash DD slash YYYY

Injury Origin(Required)

Desc Discomfort(Required)

Interfere w/ Activities:(Required)

Yes

Affected Sleep:(Required)

Yes

Missed Work:(Required)

Yes

Unable to Work from(Required)

Unable to Work Until(Required)

MM slash DD slash YYYY

Affected Appetite:(Required)

Yes

Explain(Required)

Reduced Work:(Required)

Yes

Explain(Required)

Does it Worsen:(Required)

Yes

Explain(Required)

Weathers Affects it:(Required)

Yes

Explain(Required)

Aggravates Condition(Required)

Improves Condition(Required)

Received Treatment:(Required)

Yes

Explain(Required)

X-rays Taken:(Required)

Yes

Explain(Required)

Pain level Rating-Scale 1 to 10

As its best(Required)

Please enter a number from 1 to 10.

As its Worst(Required)

Please enter a number from 1 to 10.

Current Level(Required)

Please enter a number from 1 to 10.

Same Condition Before:(Required)

Yes

Date(Required)

MM slash DD slash YYYY

Practitioner(Required)

Goals for Your Care

People see a chiropractor for a variety of reasons. Some go for relief of pain, some to correct the cause of the pain and others for correction of whatever is malfunctioning in their body. Your doctor will weigh your needs and desires when recommending your care program. Please check the type of care desired so that we may be guided by your wishes whenever possible.

I want the Doctor to select the type of care appropriate for my condition

Relief care: Symptomatic relief of pain or discomfort.

Corrective care: Correcting and relieving the cause of the problem as well as the symptom

Comprehensive care: Bring whatever is malfunctioning in the body to the highest state of health possible with Chiropractic Care

Personal Health History

Last Physical Exam(Required)

MM slash DD slash YYYY

Primary Phys(Required)

Phys Phone #(Required)

Phys City(Required)

Phys State(Required)

Phys Zip(Required)

Health Conditions(Required)

Previous Chiro Care:(Required)

Yes

Date(Required)

MM slash DD slash YYYY

Condition(s) treated(Required)

Chance Pregnant:(Required)

Yes

Planning:(Required)

Yes

Medications(Required)

Supplements(Required)

Health Checklist:

Alcoholism

Arteriosclerosis

Autoimmune Disease

Breast Lump

Cancer

CHF

COPD/emphysema

Dementia/Alzheimer's

Diagnosed emotional/mental

Epilepsy

Fatigue

Glaucoma

Hemorrhoids

Irregular Heart Beat

Kidney Stones

Loss of Memory

Lung disease

Nosebleeds

Polio

Retinal Disease

Shortness of Breath

Sleep Problems/Insomnia

Stroke

Thyroid Condition

Varicose Veins

Allergies

Arthritis

Back Pain

Bronchitis

Cataracts

Cold Extremities

Cramps

Depression

Digestion Problems

Excessive Menstruation

Frequent Urination

Gout

High Blood Pressure

Irregular Menstrual Cycle

Liver disease/cirrhosis

Loss of Smell

Macular Degeneration

Pacemaker

Poor Posture

Sciatica

Sinus Infection

Smoked

Swelling of Ankles

Tuberculosis

Venereal Disease

Anemia

Asthma

Bleeding Disorders

Bruise Easily

Chest Pain

Constipation

CVA (stroke/TIA)

Diabetes

Dizziness

Eye Pain or Difficulties Gallbladder disease/stones

Headache

Hot Flashes

Kidney Infection

Loss of Balance

Loss of Taste

Migraines

Parkinson's

Prostate Trouble

Seizures

Skin Sensitivity

Spinal Curvatures

Swollen Joints

Ulcers

Other

Have you had any of these Cardiovascular Diseases? Please select all that apply.

Myocardial infarction

Bypass surgery

Hypertension

Coronary artery disease

Hypercholesterolemia

Do you have Diabetes? If so what type?

Type I

Type II

Juvenile

Do you have any stomach/digestive issues? Please select all that apply.

Ulcers

Reflux

IBS

Family Health History

Family Health History(Required)

I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.

Signature(Required)

Date(Required)

MM slash DD slash YYYY