New Patient Information
East West Chiropractic and EWC
Today's Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Full Name
*
Guardian's Name (if minor)
Address
*
Address
Street Address Line 2
City
State
Zip
Birth Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
Ethnicity
Gender
Male
Female
Cell Phone
*
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Email
*
example@example.com
Occupation
*
Employer
Primary Care Physician
Primary Care Physician City
Marital Status
*
Married
Single
Widowed
Divorced
Emergency Contact
*
Relationship
*
Phone #
*
Format: (000) 000-0000.
Are you insured?
*
Yes
No
Insurance Company
ID#
Group #
Cardholder's Name
Cardholder's Date of Birth
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Social Security #
Is this visit the result of a work or auto injury?
*
Yes
No
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Reason for Visit
Describe the purpose of this visit
*
How did this condition begin?
*
When did this condition begin?
*
Is this condition:
*
Getting worse
Not changing
Getting better
Is this condition:
*
Constant
Comes and Goes
What makes it better? (rest, ice, heat, positioning, etc.)
*
What makes it worse? (check all that apply)
*
Sitting
Standing
Walking
Changing positions
Twisting
Lifting
Laying/Sleeping
Reaching
Bending
Going up/downstairs
Deep breaths
Cough/Sneeze/Bowel movements
Other
Does the pain:
*
Stay in one spot
Travel to other areas
Describe the pain:
*
Ache
Sharp
Shooting
Burning
Pins and Needles
Numbness
Other
Is your pain worse in the:
*
AM
PM
No difference
Please rate the severity of your pain when it's at it's BEST
*
1
2
3
4
5
6
7
8
9
10
Please rate the severity of your pain when it's at its WORST (10 being the worse)
*
1
2
3
4
5
6
7
8
9
10
Please rate the AVERAGE severity of your pain (10 being the worst)
*
1
2
3
4
5
6
7
8
9
10
Has this condition occurred before? If yes, how often?
*
Have you ever seen other doctors/massage/acupuncture, etc. for this condition?
*
Yes
No
Name(s) of practitioner
Types of Treatment
Did it help?
Yes
No
Temporary Relief
Other past injuries: (i.e. car accidents, falls, etc.)
*
Any other odd/unusual changes in the last few months: (i.e. unexplained weight loss/gain, fatigue, changes in bowel/bladder function,
Please mark the location of your pain on the drawing below:
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Who referred you to this office?
*
Have you ever received chiropractic care before?
*
Yes
No
If yes, where?
Reason for care?
Date of last treatment (approximate)?
What types of treatment did you receive?
Current Medications and Supplements (click all that apply)
*
High Blood Pressure
High Cholesterol
Anti-anxiety
OTC NSAIDs (Tylenol, Motrin, etc.)
Prescription Pain Medication
Thyroid Medication
Antibiotics
Insulin
Blood Thinner
Allergy
Steroids/Anti-inflammatory
Muscle Relaxers
Anti-depressent
Medical Marijuana
Multivitamin
Probiotic
Omegas
Fiber
Vitamin C
Vitamin D
Calcium
Turmeric
None of the above
Other
Please select each of the diseases or conditions you have now or have had in the past (select all that apply)
*
High Blood Pressure
Low Blood Pressure
Headaches
Migraines
Thyroid Problems
Diabetes
HIV/AIDS
Cancer/Chemotherapy
Gout
High Cholesterol
Dizziness
Anxiety
Hepatitis
Osteoporosis
Anemia
Kidney Disease
Heart Disease
Stroke
Depression
Liver Disease
Multiple Sclerosis (MS)
Bleeding Disorders
Pacemaker
Heart Attack
Epilepsy
Arthritis
Joint Replacement
Rheumatoid Arthritis (RA)
Emphysema
Parkinson's Disease
Medical Implants
None of the above
Other
If you have a medical implant, what type?
Please list any past surgeries and the date they occurred
*
Do you smoke?
*
Yes
Former
Never
If you smoke, how many packs per day?
How many alcoholic beverages do you have a week?
How many cups of coffee/caffeine do you have a day?
How many ounces of water do you drink per day?
Do you exercise? If yes, what type and how often?
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For Women Only
Last Menstrual Cycle
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are you taking birth control?
If yes, what type?
Are you pregnant?
*
If yes, when are you due?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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