Chiropractic New Patient Form

Patient Number:

Date

Name:

Cell #:

Home #:

Email address

Referred By:

Address:

City:

State:

Zip:

Date of Birth:

Employer:

Occupation:

Spouse's Name:

Spouse's Employed By:

Spouse's Occupation:

HISTORY AND COMPLAINTS

AREA(S) OF PAIN:

HOW LONG HAVE YOU HAD THIS PROBLEM:

HOW OFTEN:

AT ITS WORST ARE YOU CAPABLE OF NORMAL ACTIVITY?

YES NO

HAVE YOU SEEN ANOTHER DOCTOR FOR THIS PROBLEM?

YES NO

IF YES, WHO?

IS THIS WORK RELATED (IF YES, PLEASE LET US KNOW)

YES NO

IS THIS AN INJURY RELATED TO AN AUTOMOBILE ACCIDENT?

YES NO

IF YES, WERE YOU THE ONLY OCCUPANT IN THE CAR?

YES NO

GIVE DETAILS:

HAVE YOU HAD ANY SURGERIES IN THE LAST FIVE YEARS

YES NO

LIST SURGERIES

HAVE YOU EVER SEEN A CHIROPRACTOR?

YES NO

IF YES, WHEN WAS YOUR LAST TREATMENT?

DR. NAME AND ADDRESS:

PLEASE LIST ALL OF THE MEDICATIONS YOU ARE TAKING:

Confidential Patient History

Please complete this questionnaire. Your answers will help us determine if chiropractic can help you. If we do not believe your condition will respond satisfactorily, we will not accept your case.

Please circle the appropriate letter for any of the following symptoms you have or have had previously. We want all of the facts about your health before we accept your case. THIS IS A CONFIDENTIAL HEALTH REPORT.

O - Occasionally | F - Frequently | C - Constantly

General

Muscle and Joint

Pain or Numbness in:

Gastro-Intestinal

Ears, Nose & Throat

Cardiovascular

Respiratory

Skin

Genito-Urinary

For Women Only

CHECK THE FOLLOWING CONDITIONS YOU HAVE HAD

Have you had previous chiropractic care?

Yes No

If yes, date of last care:

Do you have Health and Accident Insurance?

Yes No

If yes, with what company?

Is this an Industrial Accident Case?

Yes No

PLEASE PRINT

What is your major complaint?

Other complaints

How long have you had this condition?

Have you had this or a similar condition in the past?

What activities aggravate your condition?

Is this condition getting progressively worse?

Yes No Constant Comes and Goes

Is this condition interfering with your (check all that apply)

Work

Sleep

Daily

Routine

Other

If other, specify:

How long has it been since you felt really good?

List previous diagnoses and treatments you have received for present condition

What do you believe is wrong with you?

List surgical operations and years

Drugs you now take (check all that apply)

Nerve pills

Pain killers

Muscle relaxers

"Pep" pills

Tranquilizers

Birth control pills

Other:

Dental Visits

Every 6 months Yearly Toothache or emergency Complete dentures

Age of Mattress

Select one:

Comfortable Uncomfortable

Do you use a bed board?

Are you wearing (select as appropriate)

Heel lifts Sole lifts Inner soles Arch supports

Have you been in an auto accident?

Past year Past 5 years Over 5 years ago Never

Describe

Have you ever had any mental or emotional disorders?

Yes No

When?

Have others in your family had such disorders?

Yes No

When?

FAMILY HEALTH INFORMATION

Many health problems are the result of hereditary spinal weaknesses, thus information about your family members will give us a better picture of your total health.

Add new row

HAVE YOU EVER

Been knocked unconscious?

Yes No

DESCRIBE BRIEFLY

Used a cane, crutch, or other support?

Yes No

DESCRIBE BRIEFLY

Been treated for a spine or nerve disorder?

Yes No

DESCRIBE BRIEFLY

Had a fractured bone?

Yes No

DESCRIBE BRIEFLY

Been hospitalized for anything other than surgery?

Yes No

DESCRIBE BRIEFLY

DO YOU:

Now take vitamins or minerals?

Yes No

DESCRIBE BRIEFLY

Think you may need vitamins or minerals?

Yes No

DESCRIBE BRIEFLY

Have an allergy to any drug?

Yes No

DESCRIBE BRIEFLY

Date of Last:

Spinal Examination