Patient Information
Name
*
First Name
Last Name
Gender
Date of Birth
*
-
Month
-
Day
Year
Date
Age
Height
Weight
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Person
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Relationship
*
Medical Doctor's Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Hospital Name
Medical History
Do you have any of the following health conditions?
*
Alcoholism
Allergy shots
Anemia
Anorexia/Bulimia
Appendicitis
Arthritis
Asthma
Bleeding disorders
Cancer
Cataracts
Chemical dependency
Diabetes
Emphysema
Epilepsy
Fractures
Glaucoma
Goiter
Gout
Heart disease
Hepatitis
Hermia
Herniated disk
High blood pressure
High cholesterol
Kidney disease
Liver disease
Migraine headaches
Miscarriage
Multiple sclerosis
Osteoprosis
Pacemaker
Parkinson's disease
Pinched nerve
Prostate problem
Prosthesis
Psychiatric care
Rheumatoid arthritis
Stroke
Thyroid problems
Tumors, growths
Ulcers
Varicose Veins
NONE
Is there a family history of the following medical diagnosis?
*
Cardiovascular disease
Cancer
Asthma
Arthritis
Osteoporosis
Migraine Headaches
Other
Are you pregnant or nursing? (Female)
Yes
No
Do you exercise?
None
Moderate
Daily
Heavy
Occupation
Work Activity
Sitting
Standing
Light Labor
Heavy Labor
Do you smoke, how many packs/day?
Do you drink alcohol, how many drinks/week?
Do you drink caffeine drinks/coffee, how many cups/day?
Do you have a high stress level, what's the reason?
Are you currently taking any medications? If yes, please list them below:
Do you have any allergies? If yes, please explain allergy reaction below:
Were you previously hospitalized? If yes, please indicate when and why:
Did you undergo any surgery in the past? If yes, please indicate the name and location of the surgery:
Patient Condition
Purpose of visit or complaint
*
On scale of 1-10, how much pain are you feeling right now?
*
1
2
3
4
5
6
7
8
9
10
MINIMAL
WORST
1 is MINIMAL, 10 is WORST
What type of pain are you experiencing?
Numbness
Sharp pain
Tingling
Burning
Dull pain
Stiffness
Throbbing
Aching
Swelling
Shooting
Cramping
When did you start experiencing this problem?
-
Month
-
Day
Year
Date
Is this condition getting worse?
Yes
No
Unknown
How often do you have this pain?
Does the pain interfere with your
Work
Sleep
Daily Routine
Recreation
Other
Activities or movements that are too painful to perform?
Sitting
Standing
Walking
Bending
Laying Down
Other
How did you hear about our office?
Authorization and Consent
I consent to being treated by Dr. Laura Wood.
I confirm that all information given in this form is true, complete, and accurate.
I release this organization for any responsibility in case of accident, illness, or injury.
HIPAA:
I confirmed that I have read and received the HIPAA Privacy Practices of this chiropractor's office regarding protected health information (The other attachment in your new patient e-mail)
Signature of the Patient
*
Date
*
-
Month
-
Day
Year
Date
Submit
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