AdultNewPatient

ADULT HEALTH QUESTIONNAIRE
Name*

First Name Last Name
Age
Date of Birth*

MonthDay Year
Date
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Gender*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Marital Status*
Employer
Occupation
Spouse's Name:
Who may we thank for referring you to our office?*
CHIROPRACTIC HISTORY
Have you been evaluated or adjusted by a Chiropractor before?*
If yes, Name of Doctor, and date of last

MonthDay Year
Date
What was the reason for those visits?
Were you satisfied with your care?
REASON FOR VISIT*

wellnessnutritionpain complaint
Please describe*
What date did this begin?

MonthDay Year
Date
Did this problem start:

suddenlygraduallyafter an injury
Has this problem:

stayed the samegotten bettergotten worsecomes and goes
What makes the problem better?
What makes the problem worse?
Does this problem interfere with :

worksleepdaily routineOther
Please describe the quality of pain, mark all that apply:

dullachesharpshootingtinglingnumb
Does the pain radiate/travel: yes/no. If yes, to where?
Rate the severity of the pain (0=no pain, 10= E.R visit)
Does the pain change throughout the day? If yes, please explain:
Have you seen other doctors for this complaint?
Type of treatment received:
HEALTH HABITS
Do you smoke: Yes/No/used to. How many packs a day?*
Do you drink alcohol? Yes/No. How many drinks a week?*
Do you drink coffee, tea or soda? Yes/No. How many cups a day?*
How often do you exercise? What do you do for exercise?*
How would you rate your diet?*

poorfairgoodexcellentcould be better
Please list any supplements you are taking:
How many hours of sleep do you get a day?*
Do you wear:

heel liftssole liftsinner solesarch supports
Have you been diagnosed with a chronic illness? (i.e heart disease, diabetes, cancer, autoimmune disease, arthritis, etc)*
Please list any health conditions your family members have been diagnosed with: Family Member/Condition
Family Member/Condition
Family member/Condition
REVIEW OF SYSTEMS
Please mark any of the following symptoms you have experienced within the last 6 months:

headachesneck painringing in earsdizzinessvertigofeversore throatwt losswt gainblurred visionfatiguemood changesmidback paindifficulty breathingalergiessinus problemschronic coldcongestionasthmaADHDhigh blood pressurenumbness/tingling in armsbronchitisdigestion issueskidney stonesstomach problemsconstipationirritable bowelmenstrual painlow back paintingling/numbness in legsreproductive problemschest painear ache
CURRENT MEDICATIONS
Please list any medications you take and your dosage
GOALS FOR YOUR CARE People seek chiropractic care for a variety of reasons. Some go for relief of pain, some go to correct the cause of pain and others go for correction of whatever is malfunctioning in their body. Your doctor will weigh your needs and desires when recommending your care program. Please check the type of care desired so that we may be guided by your wishes whenever possible. PLEASE PICK ONE.

Relief Care: Symptomatic relief of pain or discomfort.Corrective Care: Correcting and relieving the cause of the problem as well as the symptoms or pain.Comprehensive Care: Get out of pain, correct the underlying cause, and function atan optimal level.I want the doctor to select the type of care for my condition.
FEMALE PATIENTS ONLY
Are you

cyclingmonthlypremenopausalmenopausal
Are you currently pregnant?

yesno
Are you currently breastfeeding?

yesno
Are you currently using birth control?

yesno
What type?
Do you :

experience painful periodshave irregular cyclesheavy bleedingexperience infertilityannual mammograms
CONSENT for examination and care: Please Read Carefully

In order for my health professional as indicated below to make a determination on the suitability of my case for care, I acknowledge and understand that I must complete a thorough evaluation. I do hereby request and consent to the performance of such an evaluation by the person(s) named below, or any party authorized to do so by that person.

I have had the opportunity to discuss with the Doctor of Chiropractic indicated below, or with any party authorized to do so by that Chiropractor, about the nature and purpose of the examination process. I understand that there may be remotely associated risks with examinations, as there are with any and all healthcare treatments. In healthcare, the matter of whether any treatment is appropriate or not is determined by looking at the level of risk and comparing this with the level of expected benefit. I understand that I may ask the doctor to stop the examination at any time. I also understand that by signing this form, the chiropractor continues to be obligated for best practices delivered in my interests.
Name*
Signature*

Clear
Date*

MonthDay Year
Date
Doctors of Chiropractic: Dr. Stephanie Wigner, DC, Dr. Monika Luto, DC Address: 2621 Bridge Ave Point Pleasant NJ 08742/ 43 Main Street Avon By The Sea 07717
24 HOUR CANCELLATION POLICY
Due to the high volume of appointments and our commitment to having your wait time remain short, we have decided to implement a 24 hour cancellation policy. This allows us to fit everyone into our schedule that needs to be seen while respecting your time. We've never wanted to be an office that double books appointments, therefore causing you to wait 20+ minutes to be seen. However, our schedule is often full and the last minute cancellations are unfair to those needing appointments whom we've turned away. Every family member that is cancelled less than 24 hours in advance will be charged a $50 cancellation fee. We appreciate you and want to continue to serve you at a high level.

To cancel or reschedule your appointment, please call us at 732-295-4000 or text us at 732-701-7407. If you cannot reach us or it is outside office hours please leave a detailed message with your name and phone number. We will return your call promptly.

By signing below, you acknowledge that you have read and understand the cancellation policy.
Name*
Signature*

Clear
Date*

MonthDay Year
Date
Should be Empty:

ADULT HEALTH QUESTIONNAIRE

CHIROPRACTIC HISTORY

HEALTH HABITS

REVIEW OF SYSTEMS

CURRENT MEDICATIONS

FEMALE PATIENTS ONLY

24 HOUR CANCELLATION POLICY