New Practice Member Application
Please answer each question to the best of your ability
First Name
*
Last Name
*
Age
*
Date
-
Month
-
Day
Year
Date
Date of Birth
*
-
Month
-
Day
Year
Date
Biological Sex
Male
Female
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
Provide a valid email address; we will use it for receipts and case-related patient communications.
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Status
Single
Married
Divorced
Widowed
Spouse's Name
Occupation
Employer
How did you hear about us?
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Next
Health Concerns
List The Health Concerns That Brought You Into This Office Below. Leave Other Fields Blank If NOT applicable.
First Concern
Please fill this out to the best of your ability. If the question does not apply to you, please leave it blank.
Rate of Severity
Please Select
0
1
2
3
4
5
6
7
8
9
10
(0) = No Pain or Irritability - Feeling Great. (10) = Unbearable; Extreme Intolerance
When did this problem start?
Please Select
Today
Past Week
Past Month
Months Ago
Years Ago
Have you had this problem before? When?
Ex: Yes, 10 Years ago
Did the problem begin with an injury?
Please Select
Yes
No
If Yes, we will discuss this in the office
Are symptoms Constant or Intermittent
Please Select
Constant
Intermittent
Intermittent = Comes and goes
Second Concern
Please fill this out to the best of your ability. If the question does not apply to you, please leave it blank.
Rate of Severity
Please Select
0
1
2
3
4
5
6
7
8
9
10
(0) = No Pain or Irritability - Feeling Great. (10) = Unbearable; Extreme Intolerance
When did this problem start?
Please Select
Today
Past Week
Past Month
Months Ago
Years Ago
Have you had this problem before? When?
Ex: Yes, 10 Years ago
Did the problem begin with an injury?
Please Select
Yes
No
If Yes, we will discuss this in the office
Are symptoms Constant or Intermittent
Please Select
Constant
Intermittent
Intermittent = Comes and goes
Third Concern
Please fill this out to the best of your ability. If the question does not apply to you, please leave it blank.
Rate of Severity
Please Select
0
1
2
3
4
5
6
7
8
9
10
(0) = No Pain or Irritability - Feeling Great. (10) = Unbearable; Extreme Intolerance
When did this problem start?
Please Select
Today
Past Week
Past Month
Months Ago
Years Ago
Have you had this problem before? When?
Ex: Yes, 10 Years ago
Did the problem begin with an injury?
Please Select
Yes
No
If Yes, we will discuss this in the office
Are symptoms Constant or Intermittent
Please Select
Constant
Intermittent
Intermittent = Comes and goes
Fourth Concern
Please fill this out to the best of your ability. If the question does not apply to you, please leave it blank.
Rate of Severity
Please Select
0
1
2
3
4
5
6
7
8
9
10
(0) = No Pain or Irritability - Feeling Great. (10) = Unbearable; Extreme Intolerance
When did this problem start?
Please Select
Today
Past Week
Past Month
Months Ago
Years Ago
Have you had this problem before? When?
Ex: Yes, 10 Years ago
Did the problem begin with an injury?
Please Select
Yes
No
If Yes, we will discuss this in the office
Are symptoms Constant or Intermittent
Please Select
Constant
Intermittent
Intermittent = Comes and goes
Have you seen other doctors for these conditions?
Yes
No
If Yes:
Chiropractor
Medical Doctor
Other
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Next
Please select ALL conditions that you are CURRENTLY having:
Headaches,
Migraines,
Jaw/TMJ Pain,
Neck Pain,
Shoulder Pain,
Arm Pain,
Upper Back Pain,
Mid-Back Pain,
Lower Back Pain,
Hip/Leg Pain,
Knee Pain,
Foot Pain,
Ear Infections,
Hearing Loss,
Ringing in Ear(s),
Dizziness,
Loss of Energy,
Nervousness,
Double/Blurry Vision,
Anxiety,
ADD/ADHD,
Loss of Balance,
Depression,
Allergies,
Sinus Issues,
Frequent Colds,
Thyroid Issues,
Asthma,
Chest Pain,
Heart Problems,
Nausea,
Ulcers,
Digestive Issues,
Diarrhea,
Constipation,
Bed Wetting,
Kidney Problems,
Bladder Problems,
Menstrual Problems,
Prostate Problems,
Infertility,
Fibromyalgia,
Epilepsy/Convulsi-ons,
Tremors,
Disc Problems,
Scoliosis,
Poor Posture,
Skin Problems,
Sexual Dysfunction,
Sleep Problems,
Tight/Sore Muscles,
Sports Injury,
Sciatica,
Sleep Problems,
Tight/Sore Muscles,
Arthritis/Joint Pain,
GERD/Gastric Reflux,
Numb/Tingling in arms/hands,
Numb/Tingling in legs/feet,
Stomach Problems,
High/Low Blood Pressure,
Difficulty Breathing,
Pregnant?
Yes
No
If Yes, Due Date?
-
Month
-
Day
Year
Date
What Relieves Your Symptoms? (Add multiple choices if needed)
Ex: Ice, Stretching, Massage, Heat, Medication, Rest, Other (specify)
What Make Your Symptoms Worse? (Add multiple choices if needed)
Ex: Movement, Lifting, Standing, Running, Exercise, Bending, Sitting, Walking, Activity, Everything, Other (specify)
When is (are) the problem(s) at its worst?
Morning
Afternoon
Mid-Day
Late Afternoon (Bedtime)
List All Surgical Operations and Years
Ex: Right leg ACL Surgery - 2012
List any other injuries to your spine, minor or major that the doctor should know about:
List all over the counter (OTC) & prescription medication you are on and the reason for each:
Ex: Amoxicillin - Pneumonia
Have you ever been in an auto accident? List All:
Ex: Rear ended - 2015
Have you ever been knocked unconscious?
Yes
No
Fracture a Bone?
Yes
No
Social History
Smoking (How Often?)
Daily
Weekends
Occasionally
Never
Alcohol (How Often?)
Daily
Weekends
Occasionally
Never
Exercise (How Often?)
Daily
Weekends
Occasionally
Never
ACTIVITIES OF LIFE
Please identify how your current condition is affecting your ability to carry out activities that are routinely part of your life:
Activities of Life
Rows
No Effect
Painful (Can Do)
Painful (Limits)
Unable to Perform
Sit to Stand
Carry Groceries
Climb Stairs
Pet Care
Driving
Extended Computer Use
Household Chores
Lifting Children
Dressing
Sexual Activity
Sleeping
Sitting
Standing
Walking
Washing/Bathing
Sweeping/Vacuuming
Yard Work
Garbage
Concentration (Reading)
Tells Us YOUR Story - What is happening and why is it important that you heal?
Family Health History
This Form is to Assist the Doctors by Providing Past Health History Information for Their Review
Rows
Spouse
Son
Daughter
Mother
Father
Headache
Neck Pain
Jaw/TMJ Pain
Shoulder Pain
Back Pain
Hip/Leg Pain
Arthritis/Joint Pain
Ear Infections
Hearing Loss
Dizziness
Loss of Energy
Nervousness
Blurred/Double Vision
Anxiety
ADD/ADHD
Depression
Allergies
Sinus Issues
Thyroid Problems
Asthma
Breathing Problems
Heart Problems
High/Low Blood Pressure
Stomach Problems
Bed Wetting
Infertility
Sciatica
Fibromyalgia
Poor Posture
Sleep Problems
Stroke
Cancer
Heart Disease
Diabetes
Arthritis
Alzheimer's
Age Rating
Chronicity
Degeneration
MSK|ORG
Chiro Criteria
Submit
Should be Empty: