New Patient Form

WILSON CHIROPRACTIC

Dr. Jeff Wilson | Dr. Britney Ward

Today's Date

Patient Information

Patient's Name:

Nickname:

Date of Birth:

Email Address:

Address (Home):

City:

State

Zip Code:

Phone Number:

Emergency Contact Information

Name:

Phone:

Who can we thank for referring you in?

Insurance Information

Will you be filing with insurance?

Yes No

*If yes, please provide a copy of your insurance card(s) to our front desk staff.

Reason for Visit

What brings you in today?

When did this condition begin? (month and year)

What caused this condition to occur?

Rate the severity of your discomfort at its worst, on a scale of 1-10 with 1 being the least severe and 10 is the most severe. Choose the number that applies to you at this moment

0 - None

1-3 Mild

4-6 Moderate

7-10 Severe

How often do you feel this discomfort? Choose one.

75%-100% of the time

50%-75% of the time

25%-50% of the time

0%-25% of the time

How has this complaint changed since the onset?

Has gotten worse

Stayed the same

Slowly getting better

What activity/activities are most significantly affected by this complaint? (walking, sitting, sleeping, standing, housework, etc.)

Have you received any treatment for this condition? If yes, please explain briefly what care you have received.

Have any other health care provider(s) performed tests related to this condition?

Yes No

Have you ever had any previous episodes of this condition?

Yes No

If Others, Specify

Do you have any additional concerns currently?

Yes No

If yes, please explain:

Current Health

please list here:

*If you answered yes to any of the above, please share this information with your doctor*

Personal and Family History

Have you had any surgical procedures?

Yes No

If yes, please explain:

Do you have any history of accidents or traumas?

Yes No

If yes, please explain:

Are there any past illness or conditions we should be aware of, such as cancer, diabetes, hypertension?

Yes No

If yes, please explain:

Are you presently taking any medications?

Yes No

If yes, please explain:

Do you have a past family illness history, such as diabetes, cancer, hypertension, and progressive neurological diseases that we should be aware of?

Yes No

If yes, please explain:

*If you have answered yes to any of the above, please share this information with your doctor*

Work, Social, Habits

Current Work Habits. Choose all that apply.

Permanently fully disabled

Permanently partially disabled

Cannot work due to current condition

Full-time (20-40+ hours/week)

Part-time (1-19 hours/week)

Retired

Student

Unemployed

Personal Social Habits. Choose all that apply. Tobacco Products:

Never been a smoker

Former Smoker

Light Use

Moderate Use

Heavy Use

If yes, how often do you smoke:

Everyday

Just sometimes

Are you interested in quitting smoking?

Yes No

If yes, on a scale of 1-10, 10 being very interested, how interested are you in quitting?

Alcohol Use:

None

Light Use

Moderate Use

Heavy Use

Coffee/Caffeine Use:

None

Light Use

Moderate Use

Heavy Use

Recreational Drug Use:

None

Light Use

Moderate Use

Heavy Use

Exercise Habits. Choose all that apply.

No current exercise habits

Exercise daily

Exercise 3+ times per week

Cannot return to exercise due to current condition

Other, please discuss with doctor

Briefly explain the types of exercise you do:

Diet and Nutrition Habits. Choose all that apply.

Vegan or Vegetarian

Balanced Nutrition

Controlled

Restricted

1 to 2 meals a day

2 to 3 meals a day

More than 3 meals a day

Daily Supplements taken

Are you interested in having a nutrition/exercise consultation with your doctor?

Yes No

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