New Patient Information
Name
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First Name
Last Name
Date of Birth
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Sex
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Male
Female
Address
Street Address
Street Address Line 2
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Please Select
Afghanistan
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Home Number
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Number
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Format: (000) 000-0000.
Work Number
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Format: (000) 000-0000.
Email
example@example.com
Emergency Contact
Relationship
Home Number
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Format: (000) 000-0000.
Cell Number
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Format: (000) 000-0000.
Insurance Carrier
Policy/ID#:
Group #
Subscriber
Chief Complaint
Have you been treated for this condition before?
Yes
No
If so, when?
By whom
Is this a result of a workers comp injury or auto accident?
Yes
No
Is this a result of a workers comp injury or auto accident?
Yes
No
Who may we thank for referring you to our office?
Other notes (if any):
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Patient Intake Form
Patient Name
Date
Indicate on the drawings below where you have pain/symptoms:
How often do you experience your symptoms?
Consistently (76-100% of the time)
Frequently (51-75% of the time)
Occasionally (26-50% of the time)
Intermittently (1-25% of the time)
How would you describe the type of pain?
Specify symptoms to locations, if multiple sites
Rows
Location of pain
Sharp
Dull
Diffuse
Achy
Burning
Shooting
Stiff
Rows
Location of pain
Numb
Tingly
Sharp with motion
Shooting in motion
Stabbing with motion
Electric with motion
Other
How are your symptoms changing with time?
Getting worse
Staying the same
Getting better
Using a scale of 0-10 (10 being the worst), how would you rate your problem?
Best
0
1
2
3
4
5
6
7
8
9
Worst
10
0 is Best, 10 is Worst
How much has the problem interfered with your work?
Not at all
A little bit
Moderately
Quite a bit
Extremely
How much has the problem interfered with your social activities?
Not at all
A little bit
Moderately
Quite a bit
Extremely
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Who else have you seen for your problems?
Chiropractor
Neurologist
Primary care physician
ER physician
Massage therapist
Orthopedist
Physical therapist
Other
No one
How long have you had this problem?
How do you think your problem began?
Do you consider this problem to be severe?
Yes
At times
No
What aggravates your problem?
What alleviates your problem? If any:
What concert you most about your problem? What does it prevent you from doing?
What is your weight?
What is your height?
What is your occupation??
How would you rate your overall health?
Excellent
Very good
Good
Fair
Poor
What type of exercise do you do?
Strenuous
Moderate
Light
None
Indicate if you have any immediate family members with any of the following:
Rheumatoid Arthritis
Diabetes
Lupus
Heart problems
Cancer
ALS
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For each of the conditions listed below, place a check in the "past" column if you have had the condition in the past. If you presently have a condition listed below, place a check in the "present" column
Rows
Past
Present
Headaches
Neck pain
Upper back pain
Mid back pain
Lower back pain
Elbow/Upper arm pain
Wrist pain
Hand pain
Hip pain
Upper leg pain
Knee pain
Ankle/Foot pain
Jaw pain
Joint pain/stiffness
Arthritis
High blood pressure
Heart attack
Chest pain
Stroke
Angina
Rheumatoid arthritis
Cancer
Tumor
Asthma
Chronic Siniusitic
Liver/Gallbladder disorder
General fatigue
Muscular incoordination
Rows
Past
Present
Visual disturbances
Dizziness
Kidney stones
Kidney disorders
Bladder infection
Painful urination
Loss of bladder control
Prostate problems
Abnormal weight gain/loss
Loss of appetite
Abdominal pain
Ulcer
Hepatitis
Diabetes
Excessive thirst
Frequent urination
Smoking/tobacco use
Drug/alcohol dependence
Allergies
Depression
Systemic lupus
Epilepsy
Dermatitis/Eczema/Rash
HIV/AIDS
Birth Control Pills (females only)
Hormonal replacement (females only)
Pregnancy (females only)
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List all prescription medications you are currently taking:
List all of the over-the-counter medications you are currently taking:
List all surgical procedures you have had:
What activities do you do at work?
Rows
Most of the day
Half of the day
A little of the day
Sit
Stand
Computer work
On the phone
What activities do you do outside of work?
Have you ever been hospitalized?
Yes
No
If yes, why?
Have you been to a chiropractor before?
Yes
No
If yes, how long ago?
How did you feel the results from treatment were?
Great
Good
Fair
Mixed
Poor
Have you had significant past trauma?
No
Yes
Anything else you would like the doctor to know?
Signature
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Date
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Month
-
Day
Year
Date
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