Patient Data

New Patient Health History form MUST be completed IN ITS ENTIRETY prior to seeing the Doctor. This allows us time to be as prepared as possible for your visit. Thank you (:

Name *
Name
Today's Date *
Today's Date
Address *
Address
Phone *
Phone
Birthdate *
Birthdate
Emergency Contact Phone *
Emergency Contact Phone
Primary Care Physician Phone Number
Primary Care Physician Phone Number
Current Complaints
Nature of Injury *
Date of Injury *
Date of Injury
Date Symptoms Appeared *
Date Symptoms Appeared
Has It Affected Your Work? *
Has It Affected Your Social Life, Including Excercise *
Have You Had To Miss Work? *
Date You Last Worked *
Date You Last Worked
Have You Ever Had The Same Condition? *
Have You Ever Been Under Chiropractic Care?
INSURANCE INFORMATION
Do You Have Health Insurance? *
SIGNATURES
Date *
Date
Date
Date
MEDICAL HISTORY
Have You Been Treated for Any Conditions In the Last Year? *
Date of Last Physical Exam? *
Date of Last Physical Exam?
Is There a Chance That You Are Pregnant? *
Have You Had X-Rays, MRI, CT or Other Imaging Taken? *
HAVE YOU EVER:
Broken Bones?
Dislocations
Been Hospitalized?
Been In an Auto Accident
Had Sprains/Strains
Been Struck Unconscious or Other Head Injuries?
Had Surgery?
FAMILY HISTORY
How Often Do You Experience Pain
Do Your Symptoms Interfere with Daily Life?
Does Pain Wake You up at Night?
Are Your Symptoms Worse During Certain Times of the Day?
Do Changes in Weather Affect Your Symptoms?
Do You Wear Orthotics?
Do You Take Vitamin Supplements?
On a Scale of 1-10 (10 Being the Worst), How Would You Rate Your Pain?
How Would You Describe Your Pain?
HABITS
Alcohol
Coffee
Tobacco
Drugs
Exercise
Sleep
Appetite
Soft Drinks
Water
Salty Foods
Sugary Foods
Artificial Sweeteners
HAVE YOU EVER SUFFEDRED FROM:

Your Health Care Provider and Members of the Practice Staff May Need to Use Your Name, Address, Phone Number, and Your Clinical.