Stamford Family Wellness Intake Form

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Personal History
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Email
example@example.com
Date of Birth

MonthDayYear
Date
Age
Gender Identity and Pronouns
What is your Gender? If other, please indicate your preferred pronoun
Social Security Number
All submissions are kept private and confidential
Marital Status
Business Employer
Type of Work
Name of Spouse
Name and Ages of Children
Name and Number of Emergency Contact.
Relationship to Emergency Contact
Who is Responsible for Your Bill, You and

Other
Personal Health Insurance Name, if you don't have insurance, type None
Health Card Number
Insured Person’s Name
Insured Date of Birth

MonthDayYear
Date
Current Unwanted Health Condition
Unwanted Health Conditions
Other Doctors Seen Names and what type of practitioner
Type of Treatment
Results of Treatment
When Did This Condition Begin?

MonthDayYear
Date
Has This Conditon Occured Before?
Please Outline On The Diagram The Area of Your Discomfort.
Is Condition

Other
Date of Accident

MonthDayYear
Date
Are you currently taking any medication?
Do you have any medication allergies?
Do you use or do you have history of using tobacco?
Do you use or do you have history of using illegal drugs?
Type a question
Have You Made A Report of Your Accident To Your Employer
Drugs You Now Take

Other
Do you Suffer From Any Other Condition Than That Which You Are Now Consulting With Us?
Past Health History
Please Describe Any Previous Surgeries.
Please Describe Any Major Accidents Or Falls
Please Tell Us About Any Hospitalizations Other Than Above
Have You Had Previous Chiropractic Care? When Was Your Last Visit
CHECK ANY OF THE FOLLOWING YOU HAVE HAD IN THE PAST 6 MONTHS:
MUSCULO-SKELETAL CODE
NERVOUS SYSTEM CODE
GENERAL CODE
GASTROINTESTINAL CODE
GENITO-URINARY CODE
C-V-R CODE
EENT CODE
MALE/FEMALE CODE

Other
IF YOU MENSTRUATE
ARE YOUR MENSTRUAL PERIODS REGULAR

MonthDayYear
Date
ARE YOUR MENSTRUAL PERIODS REGULAR
Check the conditions that apply to you or to any members of your immediate relatives:

Other
Most patients that come to our office have one of two objectives in mind concerning thier health care. Some patients come for symptomatic relief of pain or discomfort (Relief Care). Others are interested in having the cause of the problem as well as the symptoms corrected and relieved (Corrective Care). Your doctor will weigh your needs and desires when recommending your treatment program.
What Kind Of Plan Makes The Most Sense To You For Your Health?
Please Type your full name

First NameLast Name
Please enter today's date

MonthDayYear
Date
Signature
Should be Empty:

Personal History

Current Unwanted Health Condition

Past Health History