New Patient - New Consultation

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Patient Information

First name

Last name

Date of birth

Occupation

Gender

Male Female

Contact Information

Phone number

Email address

Address

Emergency Contact

Add another emergency contact

Primary Care Physician

First name

Last name

Phone number

Address

Medical History

What medications are you currently taking? And list any medication allergies.

Do you have any pre-existing medical conditions?

Example: Asthma, heart conditions, etc

Have you had any past fractures, sprains, or breaks? If so, include the type of injury, location on your body, and when the injury occurred.

List any surgeries.

Are you pregnant?

Yes No Not sure

If yes, how far along?

Is there anything else regarding your medical history that we should be aware of?

Lifestyle

Do you smoke?

Regularly Occasionally No

Do you drink alcohol?

Regularly Occasionally No

Do you exercise?

Regularly Occasionally No

Do you have a healthy and balanced diet?

Regularly Occasionally No

How are your stress levels?

High Moderate Low

Reasons for Visit

How can we serve you?

Chiropractic exam/treatment

Nutritional evaluation

Other

If other, please describe

Complete the section(s) below that apply to you, and skip the rest.

Please list your nutritional or physical/functional concerns

Describe the reason you are seeking chiropractic treatment.

When did the symptoms start?

Describe anything you think might have caused the symptoms.

Examples: Working out, posture, sleeping, etc.

Describe anything you think might aggravate the symptoms.

Examples: Reaching for items, sitting for an extended amount of time, etc.

Describe any other treatments you’re receiving for your symptoms.

Examples: Acupuncture, physical therapy, etc.

Have you experienced these types of symptoms before?

Yes No

Mark the areas on the image where you are experiencing symptoms.

Family & Household

Spouse / partner name

List your children and their ages

Type and number of pets

Employer

Employer address

Family Health History

Check any conditions that run in your immediate family

Cancer

Diabetes

Heart Disease

High Blood Pressure

Stroke

Back Problems / Pain

Arthritis

Osteoporosis

None of these

Which relative(s)?

How You Heard About Us

If referred, who may we thank?

Appointment reminder preference

Text Email Phone call

Payment / Insurance

All of our services are CASH Services. Exceptions: Medicare, and any out-of-network benefits.

How will you be handling your charges?

Cash / self-pay Medicare Out-of-network insurance benefits (must be verified)

Medicare ID

Out-of-network insurance carrier

Member ID

Group #

What can we do to make you happier?

Consent for Care

I authorize Dr. Laurie Pearce and Priority Wellness Care staff access to my information, and to provide the requested services noted above. Our Notice of Privacy Practices is posted on our website for you to download and review.

I have read and agree to the above

Date signed

Your information will be encrypted.

New Patient - New Consultation - Intake Form

Patient Information

Contact Information

Emergency Contact

Primary Care Physician

Medical History

Lifestyle

Reasons for Visit