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New Patient

  
 

Confidential Patient Health Record

1. * First Name:
2. * Last Name:
3. Nickname: (first name you prefer to be called)
4. Date of Birth:
5. Male or Female:
6. Marital Status:
7. Social Security #:
8. * Home Phone: (please include area code)
9. Work Phone: (please include area code)
10. Cell Phone: (please include area code)
11. Street Address:
12. City, State, Zip:
13. Drivers License #:
14. Business Employer:
15. Type of Work:
16. Insurance:
17. Spouse's name:
18. Spouse Day Phone: (please include area code)
19. Spouse's employer:
20. Names and Ages of Children:
31. How were you referred to our office?
32. In case of emergency, contact: (include phone number)

CURRENT HEALTH CONDITION
   
33. Unwanted Health Condition(s):
34. Is this a result of an auto accident? If yes, fill in date at #36.
35. Is this a result of a work comp injury? If yes, fill in date at #36.
36. Date of injury:
37. If a work comp injury, has the employer been notified?
38. Have you consulted any other doctors for this condition?   If yes, fill out #39-40
39. Other doctors consulted:
40. Treatment and effectiveness:
41. When did your condition(s) begin?
42. Has this condition occurred before?  
 If yes, when and how often? 
43. List over the counter or prescription drugs you are currently taking:
44. Do you wear a shoe lift?
   

PAST HEALTH HISTORY
 
46. Major Surgery/ Operations:
To make multiple selections, hold down Control while left clicking mouse.

Other: 

47. Major accidents or falls:
48. Hosptializations:
49. Have you had prior chiropractic care?
 If yes, name of doctor:
50. Approximate date of last chiropractic treatment:
   

CHECK ANY OF THE FOLLOWING DISEASES YOU HAVE HAD:

Pneumonia Mumps Influenza
Rheumatic Fever Small Pox   Pleurisy
Polio Chicken Pox Arthritis
Tuberculosis Diabetes Epilepsy
Whooping Cough Cancer Mental Disorders
Anemia Heart Disease Low Back Pain/ Sciatica
Measles Thyroid Eczema
Test HIV positive    

CHECK ANY OF THE FOLLOWING YOU INTAKE

Coffee Tea Alcohol
Cigarettes White sugar Dairy products

CHECK ANY OF THE FOLLOWING YOU HAVE HAD IN THE PAST 6 MONTHS:

Musculoskeletal System    
Low back pain General stiffness Difficulty chewing/ TMJ
Pain between shoulders Walking problems Joint pain/ stiffness
Neck pain Arm pain  
     
Nervous System    
Nervous Numbness Paralysis
Dizziness Forgetfulness Confusion
Fainting Convulsions Seizures
Stress Cold/ tingling extremities Depression
     
General Code    
Fatigue Allergies Loss of sleep
Fever Headaches  
     
Gastrointestinal/ Genitourinary Systems  
Poor/ excessive diet Excessive thirst Frequent nausea
Vomiting Diarrhea Constipation
Hemorrhoids Liver problems Gall bladder problems
Weight trouble Abdominal cramps Gas/ bloating
Heartburn Black/ bloody stool Colitis
Bladder trouble Painful urination Excessive urination
Discolored urine Urinary tract infections Kidney infections
   
Cardiovascular  System  
Chest pain Shortness of breath Blood pressure problems
Irregular heartbeat Heart problems Lung problems/ congestion
Varicose veins Ankle swelling Stroke
Vision problems Dental problems Ear Aches
EENT
Vision problems Dental problems Ear Aches
Hearing difficulty Stuffed nose
MALE/ FEMALE
Menstrual irregularity Menstrual cramps Vaginal pain/ infection
Breast pain/ lumps Prostate Sexual dysfunction

Other problems: 
If female, date of last period:
If female, are you pregnant? 
FAMILY HISTORY (check the following family members with similar problems)
Mother Father Brother
Sister Grandparent Spouse
Child    

When you have finished completing this form, click on Submit below and this information will be sent to the doctors office.  We look forward to seeing you in the clinic!