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

Email address

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

Mailing address

Address

City

State

Zip

Telephone (Cell)

Age

Birth Date

Height:

Weight:

Referred By

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

If yes, when?

List of other practitioners seen for this injury/condition

Have you ever been under chiropractic care?

Yes No

If yes, please describe

Medical History

Have 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

What vitamins, minerals, or herbs do you currently take?

Broken bones?

Yes No

Explain

Been hospitalized?

Yes No

Explain

Been in an auto accident?

Yes No

Explain

Had Sprains/Strains?

Yes No

Explain

Been struck unconscious?

Yes No

Explain

Had surgery?

Yes No

Explain

Family History

Family Members - Present and Past Health conditions

Do you experience pain every day?

Yes No

Do your symptoms interfere with daily life?

Yes No

Does pain wake you up at night?

Yes No

Are your symptoms worse during certain times of the day?

Yes No

Do changes in weather affect your symptoms?

Yes No

Do you wear orthotics?

Yes No

Do you take vitamin supplements?

Yes No

What activities aggravate your symptoms?

Medical Condition's