NEW PRACTICE MEMBER APPLICATION
Please fill this form out honestly, and to completion to of your ability.
Name
*
First Name
Last Name
Preferred Name
Date of Birth
*
/
Month
/
Day
Year
Date Picker Icon
Age
*
Gender
*
Male
Female
Marital Status
*
Single
Married
Divorced
Widowed
Address
*
Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
*
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Email Address
*
example@example.com
Spouse's Name
Number of Children
Names, Ages, Genders
Occupation
*
Employer's Name
Who may we thank for referring you?
*
Chief Complaints
List the Chief Complaints That Brought You into This Office
*
Chief Complaints
(Listed according to severity in 2-3 words)
Rate of Severity
0=no pain
10=unbearable
Primary
1
2
3
4
5
6
7
8
9
10
Second
1
2
3
4
5
6
7
8
9
10
Third
1
2
3
4
5
6
7
8
9
10
Fourth
1
2
3
4
5
6
7
8
9
10
Timeline
*
When did the problem start?
Have you had the problem before? (Yes or No)
Primary
Second
Third
Fourth
Source and Frequency
*
Did the problem begin with an injury?
Are the symptoms constant (C) or intermittent (I)?
Primary
Yes
No
C
I
Second
Yes
No
C
I
Third
Yes
No
C
I
Fourth
Yes
No
C
I
Other Health Concerns
Medical History
Have you ever seen other doctors for these conditions?
*
Yes
No
If Yes:
Chiropractor
Medical doctor
Other
Who?
Name of doctor
When?
Results?
List all over the counter & prescription medications you are currently taking, and the reason for each (if none, write "N/A"):
*
Have you ever been in an auto accident? If so, list all. If no, write "N/A":
*
Have you ever been knocked unconscious?
*
Yes
No
Fractured a bone?
*
Yes
No
If yes to either of the above, please describe:
Other Trauma:
List all surgical operations & years (if none, write "N/A"):
*
List any other injuries to your spine, minor or major, that the doctor should know about (if none, write "N/A"):
*
Habits and Frequency
Smoking (If past smoker, please let us know how long you smoked, and how long it has been since you have stopped)
*
Daily
Weekends
Occasionally
Never
Past
Alcohol
*
Daily
Weekends
Occasionally
Never
Exercise
*
Daily
Weekends
Occasionally
Never
Have you consumed any caffeine or products with caffeine in the past 48 hours?
*
Yes
No
Please Mark "P" For in The Past OR Mark "C" For Currently Have. If the symptom/condition does not apply, leave blank.
Past or Current?
Headaches
P
C
Ear Infections
P
C
Kidney Problems
P
C
Sexual Dysfunction
P
C
Migraines
P
C
Hearing Loss
P
C
Frequent Colds
P
C
Spinal Bone Fracture
P
C
Bladder Problems
P
C
Sleep Problems
P
C
Jaw/TMJ Pain
P
C
Ringing in the Ears
P
C
Thyroid Issues
P
C
Menstrual Problems
P
C
Diabetes
P
C
Spinal Surgery
P
C
Neck Pain
P
C
Dizziness
P
C
Asthma
P
C
Prostate Problems
P
C
Shoulder Pain
P
C
Loss of Energy
P
C
Chest Pain
P
C
Heart Attack
P
C
Infertility
P
C
Sciatica
P
C
Arm Pain
P
C
Nervousness
P
C
Heart Conditions
P
C
Fibromyalgia
P
C
Arthritis/Joint Pain
P
C
Upper Back Pain
P
C
Double/Blurry Vision
P
C
Nausea
P
C
Epilepsy/Convulsions
P
C
GERD/Gastric Reflux
P
C
Mid Back Pain
P
C
Anxiety
P
C
Ulcers
P
C
Tremors
P
C
Lower Back Pain
P
C
ADD/ADHD
P
C
Digestive Issues
P
C
Disc Problems
P
C
Seizures
P
C
Hip/Leg Pain
P
C
Loss of Balance
P
C
Diarrhea
P
C
Scoliosis
P
C
Knee Pain
P
C
Depression
P
C
Constipation
P
C
Poor Posture
P
C
High/Low Blood Pressure
P
C
Foot Pain
P
C
Allergies
P
C
Bed Wetting
P
C
Skin Problems
P
C
Difficulty Breathing
P
C
Pregnancy
P
C
Stroke
P
C
Cancer
P
C
Numbness/Tingling in Arms/Hands
P
C
Numbness/Tingling in Legs/Feet
P
C
Activities of Life
How does it feel when you do the following? Leave blank if the activity is painless.
Painful to Do
Unable to Perform
Carrying Groceries
Sit to Stand
Climbing Stairs
Pet Care
Driving
Extended Computer Use
Household Chores
Lifting Children
Dressing
Shaving
Sexual Activities
Sleep
Static Standing
Walking
Washing/Bathing
Yard Work
Concentration (Reading)
Taking Garbage Out
Anything else that we didn't mention above?
Activity
Painful to Do
Unable to perform
Other
Other
Quadruple Visual Analogue Scale
On a scale of 1-10, 1 being no pain and 10 being the worst possible pain.
How would you rate your pain RIGHT NOW?
*
Painless
1
2
3
4
5
6
7
8
9
Unbearable
10
1 is Painless, 10 is Unbearable
What is your typical or AVERAGE pain?
*
Painless
1
2
3
4
5
6
7
8
9
Unbearable
10
1 is Painless, 10 is Unbearable
How would you rate your pain level at its BEST?
Painless
1
2
3
4
5
6
7
8
9
Unbearable
10
1 is Painless, 10 is Unbearable
How would you rate your pain level at its WORST?
*
Painless
1
2
3
4
5
6
7
8
9
Unbearable
10
1 is Painless, 10 is Unbearable
This form is to assist the doctors by providing past health history information for their review.
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