NEW PATIENT - HEALTH INFORMATION FORM

General Information

First Name

Middle Initial

Last Name

Race

American Indian Asian Black or African American Native Hawaiian Declined to State Alaska Native White Other Pacific Islander

Ethnicity

Hispanic or Latino Not Hispanic or Latino Declined to State

Preferred Language

Email address

Smoking Status

Current Every Day Smoker Current Some Day Smoker Former Smoker Never Smoker

Smoking Start Date

Smoking End Date

In effort to quit smoking, I am currently taking:

Do you have any allergies to medication

Yes No

If yes, please indicate the following:

Add new row

Are you currently taking any new medication since your last visit?

Yes No

If yes, please indicate the following:

Add new row

Have you ever had any surgeries?

Yes No

Back Operation

Female Organs

Hernia

Thyroid

Gall Bladder

Stomach

Other:

Have you ever had X-rays taken?

Yes No

When?

By Whom?

For what ailment were these X-rays taken?

Please circle each current or past symptom listed.

RESPIRATORY

Chest Pain

Chronic Cough

Difficulty Breathing

Spitting Blood

Spitting Phlegm

GENITO-URINARY

Blood in Urine

Frequent Urinationg

Incontinence

Kidney Infection

Kidney Stones

Painful Urination

Prostate Trouble

Bed Wetting

MUSCLE AND JOINTS

Back ache

Foot Trouble

Hernia

Pain Between Shoulders

Painful Tail Bone

Stiff Neck

Spinal Curvature

Swollen Joints

Tremors

SKIN OR ALLERGIES

Bruising Easily

Dryness

Eczema

Hives/Allergies

Itching

Sensitive Skin

Skin Eruption

FEMALE ONLY

Cramps

Hot Flashes

Irregular Cycle

Painful Periods

Vaginal Discharge

Pregnant Now?

Last Pap Date

Last Menstrual Cycle

I hereby authorize the doctor to examine and treat my condition as he/she deems appropriate through the use of chiropractic health care, and I give authority for these procedues to be performed. It is understood and agreed the imaging is for examination only and the negatives will remain the property of this office, being on file where they may be reviewed.

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/Guardian's Signature:

Date:

FAMILY HEALTH HISTORY

Please review the below listed diseases and conditions and indicate those that are current health problems of a family member by selecting C below. The designation P should be used to indicate a past health problem. Leave blank those spaces that do not apply. If you require more space, use the reverse side of this form.

If Alive or Age deceased

Father

Age

Mother

Age

Spouse

Age

Brother(s)

Age

Sister(s)

Age

Children

Age

Children

Age

Please complete the following three(3) questions regarding how you feel today.

Based on the picture below, input where you have pain or other symptoms.

Add new row

2. Are you getting better?

Add new row

In the past week, on average how often have your symptoms been present?

0-25% - Occasional 26-50% 51-75% 76-100% - Constant

In general, would you say your overall health right now is:

Excellent Very Good Good Fair Poor

3. Is there anything new?

Have you had any new complaints/conditions?

No Yes

Have you had any re-injuries or events that have prolonged your recovery?

No Yes

Explain

I certify that the above information is complete and accurate to the best of my knowledge. I agree to notify this doctor immediately whenever I have changes in my health condition or health plan coverage in the future.

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 Signature:

Date:

Your information will be encrypted.