PATIENT INTAKE FORM 2025

NEW JERSEY PAIN & INJURY CENTERS PATIENT INTAKE FORM
TODAYS DATE

MonthDayYear
Date
Patient Name
Name you would like to be called
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State
Zip Code
Email
example@example.com
Primary Phone Number
Format: (000) 000-0000.
Secondary Phone Number
Emergency Contact Name
Emergency Contact Phone
Format: (000) 000-0000.
Are you under the care of any other health professional for any reason?

YESNO
How did you hear about usWho referred you
Is this your first experience with Chiropractic or Physical Therapy?

YESNO
How long has it been since youve felt good
What kind of treatments have you tried
Where were the results of the treatments
Have you been diagnosed with a specific problem
Has your condition gotten worse better or the same since it began
Have you ever had a similar condition in the past
Is there anything you are unwilling to change to get well
What do you think has prevented you from getting well in the past
WAS THIS DUE TO ANY ACCIDENT OR FALL
Occupation
Do you follow a regular exercise program?

YESNO
Bowel movements

ExcellentFairPoor
Any gas/bloating or discomfort after eating?

YESNO
How many glasses of water per day?
How many cups of coffee per day?
How much alcohol do you consume per day?
Tobacco per day?
Soda Drinks per day?
Sugar per day
Recreational drug use

YESNO
If yes, what type
Quantity
Do you have a certain craving for food or tastes?

YESNO
If yes explain
Emotions: Would you say you are mostly

HappyEasily IrritableAngryWorriedFearfulDepressed
HEIGHT
WEIGHT
Please list all medications taken: (Prescription, Herbal, Vitamin/Mineral):
Are there any issues with your head?

No ComplaintsHeadachesPoor MemoryDizziness
Are there any issues with your eyes?

No ComplaintsCorrective LenseColor BlindnessEye PainCataractsExcessive TearingEye Dryness
Are there any issues with your nose?

No ComplaintsNasal Discharge MucusBleedingLoss of SmellStuffy NoseSinusitis
Are there any issues with your ears?

No ComplaintsDischargePainPoor HearingRinging
Are there any issues with your mouth/throat?

No ComplaintsGum/teeth problemsDifficulty swallowingDryFrequent coldsTMJRoot canals and/or major dental work
Are there any issues with your skin/hair?

No ComplaintsDryOilyDandruffFalling outEarly greyRashesItchingHivesPimplesUlcerationsBruise Easily
Are there any issues with your muscles/bones?

No ComplaintsNeckUpper backLower backElbowHandsKneeFoot/AnkleMuscular painsMuscle weaknesss
Are there any issues with your lungs?

No ComplaintsAsthmaTrouble breathingCoughing with phlegmDry coughChest PainTightness in chestWheezingShortness of breath
Are there any issues with your heart?

No ComplaintsHigh blood pressureLow blood pressurePalpationsVaricose veinsBleed easilyChest discomfortAnkles Swelling
Are there any issues with your digestion system?

No ComplaintsVomitingBelchingIndigestionDistention of abdomen after eatingProblem with fatty or oily foodsConstipationDiarrhea/loose stools
Are there any issues psychologically?

No ComplaintsBad temperLoss of control/violence potentialDepressionTreated for emotional prolems in the pastEver considered or attempted suicideEasily susceptible to stress
APPLICABLE FOR WOMEN ONLY
Do you use birth control?

YesNo
If yes, what type?
How long?
Do you have pain or tender breasts?

YesNo
Do you have breast implants?

YesNo
CHECK ALL THAT APPLY (Menstruation Cycle)

IrregularLight menstrual flowHeavy menstrual flowNone
Age Menstrual Started
Age Menstrual Stopped
Cancer: Have you ever been diagnosed with cancer?

YesNo
If yes, when?
Type and Location
Current Status
Describe mothers health briefly
Describe fathers health briefly
HISTORY OF COMPLAINT
PLEASE NOTE ALL AREAS ON PICTURE WHERE YOU ARE FEELING PAIN OR SIGNIFICANT STRESS, you can use the space below to describe anything you need to communicate about the area.
I declare that the information pro on this form is accurate and complete to the best of recollection. I will inform the doctor if any other facts about my condition come to mind during the time I am in active care at this office.
Patient name
Signed
Date

MonthDayYear
Date
Witness
Should be Empty: