New Patient Questionnaire

Thank you for choosing Active Family Chiropractic!

If this is an emergency, please call 911

Patient Information

First Name

Last Name

Date of Birth

Age

Social Security Number

Home Phone Number

Cell Phone Number

Email Address

Work Phone Number

Address

City

State

ZIP Code

Gender

Male Female Other

Marital Status

Single Married Divorced Widowed

Occupation

Employer

Work Address

City

State

ZIP Code

Who may we thank for your referral?

Family Medical Doctor

If you don't have one, write None.

May we contact your medical doctor regarding your care at this office?

Yes No

Insurance Coverage Choose all that apply.

None/Self-Pay

Major Medical

Medical Savings Account

HSA/FSA

Medicare

Medicaid

HHW/HIP

Auto Insurance

Med-Pay

Worker's Compensation

Primary Insurance

Identification Number

Group Number

Secondary Insurance

Identification Number

Group Number

The following people have my permission to receive my personal health information:

Add another name.

Emergency Contact Information

Add another emergency contact.

Health Questionnaire

Height (feet)

Height (inches)

Weight (pounds)

For Other, please explain.

Describe your complaint and how it began.

Be as specific as possible.

When did your complaint first begin?

Estimate date if unsure.

Is this injury the result of an accident (auto, work, slip & fall)?

Yes No

Please explain.

How often do you experience your symptoms?

Constantly (76-100% of the day) Frequently (51-75% of the day) Occasionally (26%-50% of the day) Intermittently (0-25% of the day)

Describe the quality of your symptoms. Choose all that apply.

Dull

Ache

Sharp

Shooting

Burning

Numbness

Tingling

Tightness/Stiffness

Do your symptoms radiate?

Yes No

Where?

How are your symptoms changing?

Getting better Staying the same Getting worse

What makes your symptoms feel better?

What makes your symptoms feel worse?

Have you had this same complaint in the past?

Yes No

When?

When did you last receive treatment?

How long does it take doing this activity before pain begins?

Unit of measure

Minutes Hours

What recent diagnostic tests have you had for this complaint?

None

X-Rays

MRI

CT Scan

Ultrasound

Other

When did you have these diagnositc tests done?

Date is preferred.

Health History

In addition to the presenting complaint(s), the following conditions are also present or have happened in the past:

Please explain:

Environmental Allergies

If none, write NA.

Medicinal Allergies

If none, write NA.

Please list any past surgeries or hospitalizations. Include dates.

If none, write NA.

Please list the medications you are taking and for what conditions. Include the dosage and amounts.

If none, write NA.

Please list any supplements you are taking. Include dosage and amounts.

If none, write NA.

Please list any past accidents or traumas. Include dates.

If none, write NA.

Does anyone in your family have the following:

none

Rheumatoid Arthritis

Diabetes

Lupus

Heart Problems

Cancer

ALS

What is your current employment status?

full-time

part-time

homemaker

retired

student

unemployed

Do you use any of the following:

none

tobacco

alcohol

caffeine

recreational drugs

How often do you exercise?

never

once a week

every other day

a few times a week

daily

What kind of exercise do you do?

If none, write NA.

Are you on any specific diet or have any dietary restrictions?

Yes No

If Yes, what?

Are you pregnant or is there a chance that you are pregnant?

Yes No

Date of last menstrual period:

Your information will be encrypted.

Active Family Chiropractic

Welcome to Brownsburg's premier chiropractic clinic. Our mission is to provide our patients with the highest level of quality care, and to inspire them to choose wellness care as the cornerstone of maintaining optimal health.