NEW PATIENT INTAKE

BASS CHIROPRACTIC
New Patient Intake
NAME
DATE

MonthDayYear
Date
ADDRESS
HOME PHONE
Format: (000) 000-0000.
WORK PHONE
Format: (000) 000-0000.
CELL PHONE
Format: (000) 000-0000.
EMAIL
example@example.com
MALEFEMALE
BIRTHDATE

MonthDayYear
Date
AGE
OCCUPATION
EMPLOYER NAME & ADDRESS
SPOUSES NAME
YESNO
IF YES WHEN
WHOM MAY WE THANK FOR REFERRING YOU TO OUR OFFICE?
PLEASE CHECK ALL SYMPTOMS YOU HAVE EVER HAD, EVEN IF THEY DO NOT SEEM RELATEDTO YOUR CURRENT PROBLEM:
BACK PAINNECK PAINSTIFF NECKHEADACHESDIZZINESSFATIGUEDEPRESSIONMOOD SWINGSIRRITABILITYTENSIONSLEEPING PROBLEMSPINS & NEEDLES IN ARMSPINS & NEEDLES IN LEGSNUMBNESS IN FINGERSNUMBNESS IN TOESLOSS OF SMELLLOSS OF TASTELOSS OF BALANCEDIARRHEACONSTIPATIONUPSET STOMACHMENSTRUAL PAINMENSTRUAL IRREGULARITYPROBLEM URINATINGBUZZING IN EARSLIGHTS BOTHER EYESRINGING IN EARSHEARTBURNFAINTINGNERVOUSNESSCOLD SWEATSCOLD HANDSCOLD FEETHOT FLASHESFEVERULCERS
THIS OFFICE CONFORMS TO THE CURRENT HIPAA GUIDELINES YOU MAY REQUEST A COPY OF OUR HIPAA POLICY AT THE FRONT DESK. PLEASE INITIAL TO INDICATE YOU HAVE BEEN MADE AWARE OF ITS AVAILABILITY
THE STATEMENTS MADE ON THIS FORM ARE ACCURATE TO THE BEST OF MY RECOLLECTION AND I AGREE TO ALLOW THIS OFFICE TO EXAMINE ME FOR FURTHER EVALUATION.
PATIENT SIGNATURE

Clear
DATE

MonthDayYear
Date
GUARDIAN SIGNATURE

Clear
DATE

MonthDayYear
Date
©1999-2001 Institute of Evidence-Based Chiropractic
Should be Empty:

BASS CHIROPRACTIC