New Patient Health History Form

New Patient Health History Form

Dr. Todd Gewant D.C.
Patient Data
Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
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.
Current Complaints
Please Describe
Date of Injury

MonthDayYear
Date Symptoms Appeared

MonthDayYear
Have you ever had same condition?
If yes, when?
List other practitioners seen for this injury/condition
Have you ever been under chiropractic care?
If yes, please describe
Insurance Information
Name of party responsible for payment

First NameLast Name
Phone
Format: (000) 000-0000.
Do you have health insurance?
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
2 digit month, 2 digit day, 4 digit year
Spouse's or Guardian's Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Medical History
Have you been treated for any conditions in the last year?
If yes, please describe
Date of last physical exam

MonthDayYear
Is there a chance that you are pregnant?
Have you had x-rays taken?
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:
Broken bones?
Briefly explain
Been hospitalized?
Briefly explain
Been in an auto accident?
Briefly explain
Had sprains/strains?
Briefly explain
Been struck unconscious?
Briefly explain
Had surgery?
Briefly explain
Family History
Family members - Present and past health conditions
Example: heart disease, cancer, diabetes, arthritis, etc.
Do you experience pain every day?
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?
What activities aggravate your symptoms?
Habits
Alcohol
Coffee
Tobacco
Drugs
Exercise
Sleep
Appetite
Soft Drinks
Water
Salty Foods
Sugary Foods
Artificial Sweeteners
Have you ever suffered from:
Should be Empty:

New Patient Health History Form

Patient Data

Insurance Information

Signatures

Medical History

Have you ever:

Family History

Habits