New Patient History Form

  • Patient History Form

    These forms do not load well on a Cell Phones. USE A COMPUTER TO fill out the forms
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  • I understand and agree to authorize the doctors at Life Enhancing Wellness Centers, LLC and/or the properly trained staff to administer examination procedures and treatments, as deemed necessary at that time:

  • What do you want the Doctor to help you with on your first visit?

    Where or what kind of symptom are you having?
  • Approximately when did this main problem started or become bad enough that you wanted our help?*
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  • Approximately when did this 2nd problem start or become bad enough that you wanted our help?
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  • Approximately when did this 3rd problem start or become bad enough that you wanted our help?
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  • Have you ever seen a chiropractor before?*
  • Have you ever seen a Nutritionist or Weight Loss Doctor before?*
  • Other current conditions or diseases that you dealing with NOW?*

  • Tell the Doctor about your past injuries.

    Falls, crashes, beatings, broken bones, sprains, etc. from childhood to present, list them ALL here.

  • Auto Accidents, current and past

    If your current complaint is from a recent (30 days or less or open legal case) auto accident list details in Additional Chief Complaints comments box above. List all PAST auto accidents here.

  • Work Place Injuries

    All workers comp cases and non-reported work injuries list here.

  • Sports Injuries

    From Little League to Professional athletics and everything in between.

  • Medical History

    Operations and medications
  • Smoking or Tabaco use*
  • Alcohol consumption*
  • Recreational Drug Use*
  • What health issues have you had since childhood? PAST- NOT NOW.*

  • Family History (Mother, Father, siblings

  • Father Health History*

  • Mother Health History*

  • Lifestyle, Nutritional information

    Your diet affects inflammation and pain levels
  • How many meals per day do you usually eat?*
  • Do you do any type of Special Diet or Fasting? choose the "most correct"
  • Do you eat breakfast?*
  • Do you usually have a meal or snack after 8 pm?*
  • Do you eat Sugary Treats; cakes, cookies, ice cream, candy, etc.?*
  • Do you eat Wheat - regular bread, pasta, breaded fried foods?*
  • Do you drink juice or sodas?*
  • Do you drink milk? (cow or goat)*
  • Do you eat yogurt? *
  • Servings of veggies? (your palm size is 1 serving)*
  • Servings of red meat? (4 oz is 1 serving)*
  • Servings of chicken/turkey? (4 oz is 1 serving)*
  • Servings of fish and shellfish?*
  • Do you eat eggs?*
  • Do you eat fried foods like French fires, crab cakes, fried chicken, fried fish, fried okra, etc.?*
  • Do you snack on nuts and seeds?*
  • Do you crave salty foods?*
  • Do you crave sugar or sweets?*
  • Are you an emotional eater? (eat more when upset)*
  • Should be Empty: