New Patient Health History Form

New Patient Health History Form

Dr. Todd Gewant D.C.
Patient Data
Name*

First NameLast Name
Date

MonthDayYear
Phone (Home)
Format: (000) 000-0000.
Phone (Cell)*
Format: (000) 000-0000.
E-mail (Your email will NOT be shared with any third parties, and is used for occasional office announcements and promotions.)*
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
Referred By
Age
Birth Date

MonthDayYear
Number of Children
Occupation
Employer
Marital Status
Spouse's Name

First NameLast Name
Spouse's Occupation
Spouse's Employer
Spouse's Health Status
Emergency Contact

First NameLast Name
Contact Number
Format: (000) 000-0000.
Nature of InjuryAutomobileWorkOther
Please Describe
Date of Injury

MonthDayYear
Date Symptoms Appeared

MonthDayYear
NoYes
If yes, when?
List other practitioners seen for this injury/condition
NoYes
If yes, please describe
Insurance Information
Name of party responsible for payment

First NameLast Name
Phone
Format: (000) 000-0000.
NoYes
Name of employer
Insurance company name
Contact Person

First NameLast Name
Phone
Format: (000) 000-0000.
Claim #
Signatures
Name of the Insured

First NameLast Name
I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.
Patient's Signature
Date

MonthDayYear
Spouse's or Guardian's Signature
Date

MonthDayYear
Medical History
NoYes
If yes, please describe
Date of last physical exam

MonthDayYear
NoYes
NoYes
If yes, where?
What medications are you taking and for what conditions?
Please list dosage and amounts, etc.
What vitamins, minerals or herbs do you current take?
Please list for what condition, dosage and frequency
Have you ever:
NoYes
Briefly explain
NoYes
Briefly explain
NoYes
Briefly explain
NoYes
Briefly explain
NoYes
Briefly explain
NoYes
Briefly explain
Family History
Family members - Present and past health conditions
Example: heart disease, cancer, diabetes, arthritis, etc.
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
What activities aggravate your symptoms?
Habits
NoYes
NoneLightModerateHeavy
NoneLightModerateHeavy
NoneLightModerateHeavy
NoneLightModerateHeavy
NoneLightModerateHeavy
NoneLightModerateHeavy
NoneLightModerateHeavy
NoneLightModerateHeavy
NoneLightModerateHeavy
NoneLightModerateHeavy
NoneLightModerateHeavy
AlcoholismAllergiesAnemiaArteriosclerosisArthritisAsthmaBack PainBreast LumpBronchitisBruise EasilyCancerChest PainCold ExtremetiesConstipationCrampsDepressionDiabetesDigestion ProblemsDizzinessEars RingExcessive MenstruationEye Pain or DifficultiesFatigueFrequent UrinationHeadacheHemorrhoidsHigh Blood PressureHot FlashesIrregular Heart BeatIrregular CycleKidney InfectionKidney StonesLoss of MemoryLoss of BalanceLoss of SmellLoss of TasteNeck Pain or StiffnessNervousnessNosebleedsPacemakerPolioPoor PostureProstate TroubleSciaticaSexually Transmitted InfectionShortness of BreathSinus InfectionSleep Problems or InsomniaSpinal CurvaturesStrokeSwelling of AnklesSwollen JointsThyroid ConditionTuberculosisUlcersVaricose VeinsOtherNone of the Above
Should be Empty:

New Patient Health History Form

Patient Data

Insurance Information

Signatures

Medical History

Have you ever:

Family History

Habits