New Patient Form

New Patient Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
What is your age?*
What is your gender?*
Occupation*
Phone Number*
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Person*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship*
Medical Doctor's Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Hospital Name*
Purpose of visit or complaint*
When did you start experiencing this problem?*

MonthDayYear
Date
Health Condition (Check all that apply)*

HypertensionDiabetes MellitusSpasms/CrampsConstipationSpinal Cord IssuesNeck PainLeg PainKidney DisorderHeart issuesBone problemsSprainsArthritisChronic coughBack PainInfectious DiseaseRashesBlood ClotsVaricose VeinsSeizureAsthmaHip painVision problems
Are you pregnant, breastfeed, or nursing? (Female)

YesNo
Are you smoking? If yes, how many packs a day?*
Do you exercise daily?*

YesNo
What type of exercises you do?*

StrenuousModerateLightNone
Are you wearing any implantable medical devices? If yes, what are these devices?*
Are you currently taking any medications? If yes, please list them below:*
Were you previously hospitalized? If yes, please indicate when and why:*
Did you undergo any surgery in the past? If yes, please indicate the name or location of the surgery:*
Have you experienced any pain in any part of your body? If yes, please indicate what body part. Please be specific.*
On a scale of 1-10, how much pain are you feeling right now? (1= No Pain, 10 = High Pain)*

1

2

3

4

5

6

7

8

9

10

1 is No Pain, 10 is Highest Pain
What type of pain are you experiencing?*

NumbnessTinglingDull painSharp painBurningStiffnessNone of the above
Have you have family history of the following medical diagnosis?*

Cardiovascular diseaseCancerArthritisDiabetes MellitusAsthmaOtherNone of the above
Authorization and Consent
• I confirm that all information given in this form is true, complete, and accurate.

• I released this organization for any responsibility in case of accident, illness, or injury.

• I acknowledge that no assurance was offered about the outcome.

• I acknowledge that I received an Informed Consent document and the health staff explained it to me thoroughly.

• HIPAA: I confirmed that I have read and received the HIPAA Privacy Practices of this chiropractor's office regarding protected health information.
Patient Signature*

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New Patient Form

Authorization and Consent