New Patient Information

Welcome! Please bring your insurance card and driver's license to allow our staff to make a photocopy (if applicable).
NEW PATIENT INFORMATION
Name:

First NameLast Name
Date of Birth:

DayMonthYear
Last Four Digits of Social Security Number:
Age:
Sex:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home #
Cell #
Email address:
example@example.com
Would you prefer to receive appointment confirmation or correspondence via text message?

YesNo
Occupation:
Employer:
Marital Status:
Primary Insurance Card Holder / Spouse's Information
Name:

First NameLast Name
Date of Birth:

DayMonthYear
Insurance ID#:
Group#:
Person to Notify in Case of an Emergency
Name:

First NameLast Name
Phone Number:
Please enter a valid phone number.
Relationship:
How did you hear about our office?
Medical History

Please answer the following questions to the best of your ability. This will allow us to help you obtain your goal in the least amount of time possible.
What are your symptoms? When did this condition start?
What has this condition stopped you from doing in the past?
List all physciains and practitioners you have seen for your current condition(s):
Physician Name:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Do you have any personal or family (immediate family only) history of cancer, hypertension, high cholesterol, and heart disease?

YesNo
List any medical conditions you currently have or have been diagnosed with (hypertension, heart disease, muscle complications, asthma, diabetes, etc.)
Are you currently pregnant? (if applicable)

YesNo
Have you tested positive for Covid 19? If so, when?
List any previous accidents, falls, or injuries & when:
List any medications that you are currently taking:
Have you ever been hospitalized or had any surgeries? If so, when and what?
Have you ever had any X-rays, MRIs, CT Scans, etc? If so, when?
Use the letters below to indicate the type of symptoms & location on the graph below.

A = ACHE B = BURNING

N = NUMBNESS P = PINS & NEEDLES

S = STABBING M = MUSCLE SPASMS

O = OTHER
Draw the appropriate letter over the graph below
Comments:
Relief Care: For symptoms of pain or discomfort

Corrective Care: Having the cause of the problem corrected & relieved

Preventive Care: Malfunction in their bodies brought to the highest state of health possible with Chiropractic care

These are the three phases of Chirpractic care; your doctor will weigh your needs & desires when recommending your schedule of care.
Please select the type of care you desire:

Relief CareCorrective CarePreventive CareDoctor's Recommendation
I understand and agree that health and accident insurance policies are an arrangement between insurance carriers and me. Furthermore, I understand this facility will prepare any necessary reports and form to assist in understanding and agree that all services rendered me and I am responsible for payment. I also understand that if I suspend or terminate my care, any outstanding charges will be immediately due and payable.
Patients Signature (Type Your Name)
Date

MonthDayYear
Date
Guardian or Spouse's Signature Authorizing Care (Type Your Name)
Date

MonthDayYear
Date
Should be Empty:

NEW PATIENT INFORMATION

Primary Insurance Card Holder / Spouse's Information

Person to Notify in Case of an Emergency

Medical History