New Patient Form
Patient Information
Help us get to know you better.
Name
*
First Name
Last Name
Age
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Phone Number
*
Email
*
example@example.com
Occupation
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Person
*
First Name
Last Name
Phone Number
*
Relationship
Medical Doctor's Name
First Name
Last Name
Phone Number
Hospital Name
Referral Information
Our clinic is primarily referral based. We would like to know who we can thank for sending you to us for help.
How did you hear about our clinic?
Were you ever under chiropractic care?
*
Yes
No
How important is your health to you on a scale of 1-10?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Are there any hobbies or interests that you would like to be able to do again?
Your Top 3 Health Concerns
Help us get to know your health concerns better
Please identify the top three conditions that bring you to our office:
Primary Concern
*
Secondary Concern
*
Tertiary Concern
With 10 being the most severe and 0 being normal, rate your above concerns by selecting the number
Primary Concern
Normal
1
2
3
4
5
6
7
8
9
Severe
10
1 is Normal, 10 is Severe
Secondary Concern
Normal
1
2
3
4
5
6
7
8
9
Severe
10
1 is Normal, 10 is Severe
Tertiary Concern
Normal
1
2
3
4
5
6
7
8
9
Severe
10
1 is Normal, 10 is Severe
Mark on the body where you experience symptoms
When did these problems start?
*
-
Month
-
Day
Year
Date
When are the problems at their worst?
Please Select
AM
PM
Midday
Late PM
How long does the pain last?
*
Please Select
Constant
On & off during the day
Comes & goes throughout the week
Have these concerns been treated before?
*
Yes
No
If yes, when and by whom?
How long were you under care for?
What were the results?
What helps relieve your symptoms? What makes them worse?
Health History
Help us understand your current and past health history
What type of pain are you experiencing?
*
Numbness
Sharp pain
Tingling
Burning
Dull pain
Stiffness
Were you ever diagnosed with the following conditions? If so, please indicate when.
Past
Current
Never
Broken Bones
Dislocations
Rheumatoid Arthritis
Fractures
Disabilities
Cancer
Heart Attacks
Osteo Arthritis
Diabetes
Cerebral Vascular
Any other serious conditions not listed above?
PLEASE identify ALL PAST and CURRENT conditions you feel may be contributing to your present problem:
How Long Ago
Type of Care Recieved
By Whom?
Injuries
Surgeries
Diseases
Are you pregnant, breastfeed, or nursing? (Female)
Yes
No
Are you smoking? If yes, how many packs a day?
Are you drinking? If yes, how often?
Daily
Weekends
Occasionally
Do you exercise daily?
Yes
No
What type of exercises you do?
Please Select
None
Light
Moderate
Strenuous
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:
Family History
Help us connect all the dots together
Does anyone in your family suffer from the same condition(s)?
*
Yes
No
Have they ever been treated before?
Yes
No
Any other hereditary conditions the doctor should be aware of?
Yes
No
Authorization and Consent
I
confirm
that all information given in this form is
true
,
complete
, and
accurate
.
I
acknowledge
the value and office-time commitment required for my appointment. Should I need to cancel (within 24 hours) or no-show for any appointment,
I am responsible
for the fee associated with my appointment in its
entirety
.
I
release
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.
I
authorize
payment to be made directly to Align Your Spine Chiropractic, LLC for all benefits which may be payable under a healthcare plan or from any other collateral sources.
I
authorize
use of this application for the purpose of processing claims, effecting payments, and further acknowledge that this assignment of benefits does not in any way relieve me of payment liability and that I will remain financially responsible to Align Your Spine Chiropractic, LLC for any and all services I receive at this office.
Patient's Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: