• New Patient Form

  • Congratulations! You have taken a major step toward your new and improved health and wellbeing. If you are looking for proven solutions for fixing bodies, you’ve found it. It’s been said that 90% of success is simply showing up. By spending your valuable time visiting our health center, you are “showing up”. You have demonstrated a willingness to invest in yourself. No investment could be more worthwhile! We look forward to helping you.

    Our clinic prides itself on our team approach to help care. We provide different health techniques and services in combination to get accelerated effective results. To better serve you and direct your care, please answer the following:

  • I’m here for:
  • I’m interested in the following (Select all that apply)

  • Patient Information

  • Date
     - -

  • Phone #

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Can we call you at work?
  • Date of Birth
     - -
  • Sex
  • Marital Status
  • Format: (000) 000-0000.

  • Emergency Contact

  • Format: (000) 000-0000.

  • Phone #

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Accident Information

  • Is this visit due to an accident?
  • If yes, what type?
  • Has it been reported?

  • Financial Information

  • Format: (000) 000-0000.
  • Do you have health insurance?
  • Do you have secondary insurance?
  • Date
     - -

  • Reasons for seeking chiropractic care

  • Past Health History

  • Please indicate if you have a history of any of the following:

  • Allergies

  • Medications

  • Surgeries

  • Females/ Pregnancies and outcomes

  • Family Health History

  • Do you have a family history of? (Please indicate all that apply)

  • Social and Occupational History

  • General Pain Disability Index Questionnaire

  • Date
     - -
  • Date of Birth
     - -
  • Is this your first episode of this pain?
  • Key:
    Use the letters below to indicate the type
    and location of your sensations right now
     

    A = Ache
    P = Pins & Needles
    B = Burning
    S = Stabbing
    N = Numbness
    O = Others

  • For Doctor's Use

  • Review of Systems

  • Have you had any of the following pulmonary (lung-related) issues?
  • Have you had anyof the following cardiovascular(heart-related) issues or procedures?
  • Have you had any of the following neurological (nerve-related) issues?
  • Have you had any of the following endocrine (glandular/hormonal) related issues or procedures?
  • Have you had any of the following renal (kidney-related) issues or procedures?
  • Have you had any of the following gastroenterological (stomach-related) issues?
  • Have you had any of the following hematological (blood-related) issues?
  • Have you had any of the following dermatological (skin-related) issues?
  • Have you had any of the following musculoskeletal (bone/muscle-related) issues?
  • Have you had any of the following psychological issues?

  • I have read the above information and certify it to be true and correct to the best of my knowledge, and hereby authorize this office to provide me with chiropractic care and/or physical therapy, in accordance with this state's statutes. If my insurance will be billed, I authorize payment of medical benefits to the provider for services performed.

  • Date
     - -

  • Please check all present symptoms

  • Head

  • Select all that apply

  • Neck

  • Select all that apply

  • Shoulders

  • Select all that apply

  • Arms & Hands

  • Select all that apply

  • Mid-Back

  • Select all that apply

  • Chest

  • Select all that apply

  • Abdomen

  • Select all that apply

  • Low Back

  • Select all that apply

  • Hips, Legs & Feet

  • Select all that apply

  • Women Only

  • Select all that apply

  • Men Only

  • Select all that apply

  • General

  • Select all that apply

  • NEUROLOGICAL/ MRI/  VASCULARPATIENT QUESTIONNAIRE

  • Date
     - -

  • For any YES answer, please explain under comment and notify the Doctor

  • Do you suffer from neck pain with pain in your shoulder, arms or hands?
  • Do you have weakness, numbness or burning in your shoulder, arms or hands?
  • Do your hands or arms fall asleep regularly?
  • Do you have reduced feeling (sensation) or swelling in your hands or arms?
  • Do you suffer from a loss of handgrip strength?
  • Do you suffer from back pain with pain in your buttocks, legs or feet?
  • Do you have weakness, numbness or burning in your buttocks, legs or feet?
  • Do our legs or feet fall asleep regularly?
  • Do you have reduced feeling (sensation) or swelling in your legs, feet?
  • Do you suffer from cold hands or feet?
  • Have you tried any medications such as anti-inflammatory?
  • Have you tried any Physical Therapy or Chiropractic treatments before?
  • Have you had an MRI?
  • Have you used any splint or braces or other prescribed treatment by an MD?
  • Have you used any splint or braces or other prescribed treatment by an MD?
  • If you have tried any treatment or medications, did this make your problem better?

  • NOTE:  Your health information will be kept strictly confidential.  Any information that we collect about you on this form will be kept confidential in our office.  If a claim is submitted to Medicare, your health information on this form may be shared with Medicare.  Your health information which Medicare sees will be kept confidential by Medicare.

  • Consent to Care

  • A patient coming to the doctor gives him/her permission and authority to care for them in accordance with appropriate test, diagnosis, and analyses. The clinical procedures performed are usually beneficial and seldom cause any problem. In rare cases underlying physical defects, deformities or pathologies may render the patient susceptible for injury. The doctor, of course, will not provide specific healthcare, if he/she is aware that such care may be contraindicated. It is the responsibility of the patient to make it known or to learn through health care procedures from whatever he/she is suffering from: latent pathological defects, illnesses, or deformities, which would otherwise not come to the attention of the physician.

    I agree to settle any claim or dispute I may have against or with any of these persons or entities, whether related to the prescribed care or otherwise, will be resolved by binding arbitration under the current malpractice terms which can be obtained by written request.

    I have read and understand the foregoing.

  • Date
     - -

  • X-ray Questionnaire: For women only

  • Our consultation and examination may indicate that x-rays are necessary to accurately diagnose and analyze your condition. Should x-rays be necessary we would like to confirm that you are not pregnant at this time.

    Name:         

    Select one:
                      because:      

  • Date of last menstrual period
     - -
  • Date
     - -

  • PATIENT ACKNOWLEDGEMENT OF RECEIPT OFNOTICE OF PRIVACY PRACTICES

  • Date
     - -

  • I acknowledge that I have reviewed the Notice of Privacy Practices of HealthPro. (Please initial one of the following options and sign below.)
     I wish to receive a paper copy of Privacy Notice
    I wish to receive an electronic copy of Privacy Notice

    Email Address:    
    I do not request a copy of the Privacy Notice at this time. I acknowledge that I can request a copy at any time and the Privacy Notice is posted in the office.

    Please initial below:

    I acknowledge that it is the policy of HealthPro Wellness Center to leave reminder messages on my answering machine or with another person in my home. I may make a request of an alternative means of communication (within reason) in writing.
    I acknowledge that if I should have a problem or question in regard to my rights, I may speak with the Privacy Officer about my concerns.

  • Date
     - -
  • Should be Empty: