Patient Forms

New Patient Health History Form

In order to provide you the best possible care, please complete this form and bring it to your first appointment. All information is strictly CONFIDENTIAL.

Patient Data

First Name

Last Name

Date

* Your email will NOT be shared with any 3d parties, and is used for occasional office announcements and promotions.

Mailing address

Address

City

State

Zip

Telephone (Work)

(Home)

Referred By

Age

BirthDate

Social Security #

Number of Children

Occupation

Employer

Marital Status

Spouse's Name

Spouse's Occupation

Spouse's Employer

Spouse's Health Status

Emergency Contact

Phone

Current Complaints

Nature of Injury:

Automobile Work Other

Please describe:

Date of Injury

Date symptoms appeared

Have you ever had same condition?

Yes No

List of other practitioners seen for this injury/condition

Have you ever been under chiropractic care?

Yes No

If yes, please describe

Insurance Information

Name of party responsible for payment

Phone

Do you have health insurance?

Yes No

Name of Company

• If an auto accident please provide:

Insurance Company Name

Contact Person

Phone

Claim #

Signatures

Name of the insured

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient's signature

Date

Spouse's or guardian's signature

Date

Medical History

Hove you been treated for any conditions in the last year?

Yes No

If yes, Please describe

Date of Last Physical Exam

Is there a chance that you are pregnant?

Yes No

Have you had X-rays taken?

Yes No

If Yes, where?

What medications are you taking and for what conditions (Please list dosage and amounts, etc.)

What vitamins, minerals, or herbs do you currently take? (Please list for what conditions, dosage, and frequency)

Broken bones?

Yes No

Briefly Explain

Been hospitalized?

Yes No

Briefly Explain

Been in an auto accident?

Yes No

Briefly Explain

Had Sprains/Strains?

Yes No

Briefly Explain

Been struck unconscious?

Yes No

Briefly Explain

Had surgery?

Yes No

Briefly Explain

Family History

Family Members - Present and past health conditions (Example: heart disease, cancer, diabetes, arthritis, etc.)

Do you experience pain every day?

No Yes

Do your symptoms interfere with daily life'?

No Yes

Does pain wake you up at night?

No Yes

Are your symptoms worse during certain times of the day?

No Yes

Do changes in weather affect your symptoms?

No Yes

Do you wear orthotics?

No Yes

Do you take vitamin supplements?

No Yes

What activities aggravate your symptoms?

Habits

Alcohol

None Light Moderate Heavy

Coffee

None Light Moderate Heavy

Tobacco

None Light Moderate Heavy

Drugs

None Light Moderate Heavy

Exercise

None Light Moderate Heavy

Sleep

None Light Moderate Heavy

Appetite

None Light Moderate Heavy

Soft Drinks

None Light Moderate Heavy

Water

None Light Moderate Heavy

Salty Foods

None Light Moderate Heavy

Sugary Foods

None Light Moderate Heavy

Artificial Sweeteners

None Light Moderate Heavy

Please use the following letters to indicate TYPE and LOCATION of the symptoms you currently are experiencing.

A= Ache B= Burning N= Numbness O= Other P= Pins & Needles S= Stabbing

Your information will be encrypted.