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New Patient Forms can be downloaded HERE.

• 1. Primary Patient Information

  Many of the fields on this form are required. If a required field is not applicable write or select "NONE".
• Name*
  First Middle Last
• Patient Email*
• Gender*
  ---MaleFemale
• Address*
  Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
• Primary Phone*
• Cell Phone (if different)
• Preferred Method of Contact*
  ---TextEmailPhone
• Employer Name*
• Occupation*
• Age*
• Date of Birth*
• Marital Status*
  ---SingleMarriedEngagedDivorcedWidowed
• Spouse Name
• Referred By
• Number of Children
• Children Names, Ages & Gender

• Healthcare Concerns

• Concern #1*
• Severity*
  ---12345678910
• Began*
• Had Before (When)*
• Began With Injury*
  ---YesNo
• Symptoms*
  ---ConstantIntermittent
• Concern #2
• Severity
  ---12345678910
• Began
• Had Before (When)
• Began With Injury
  ---YesNo
• Symptoms
  ---ConstantIntermittent
• Concern #3
• Severity
  ---12345678910
• Began
• Had Before (When)
• Began With Injury
  ---YesNo
• Symptoms
  ---ConstantIntermittent
• Concern #4
• Severity
  ---12345678910
• Began
• Had Before (When)
• Began With Injury
  ---YesNo
• Symptoms
  ---ConstantIntermittent
• Concern #5
• Severity
  ---12345678910
• Began
• Had Before (When)
• Began With Injury
  ---YesNo
• Symptoms
  ---ConstantIntermittent
• Seen other doctors for these conditions?*
  ---YesNo
• Chiropractor*
  ---YesNo
• Medical Doctor*
  ---YesNo
• Who and When?

• 3. Medical History

• List all Surgical Operations & Years*
  This field is required if not applicable write "NONE".
• LIST ALL Over the Counter & Prescription Medications you are on*
  This field is required if not applicable write "NONE".
• When was your last auto accident?
• Have you had previous chiropractic care?*
  ---YesNo
• If you have, please provide doctor and date.
• Have you ever been knocked unconscious?*
  ---YesNo
• Have you ever fractured a bone?*
  ---YesNo
• If knocked unconscious or fractured a bone, please describe.
• Other Trauma
• Other Problems

• 4. Insurance Information

• Primary Insurance Carrier*
• Name of Insured*
• Insured Date of Birth*
• Insured Member ID*
• Secondary Insurance Carrier
• Secondary Name of Insured
• Secondary Insured Date of Birth
• Secondary Insured Member ID
• Contact in Case of Emergency*
• Emergency Contact Phone Number*
• Social Security Number

• 5. Family Health History

• Current problems you have*
  • DIZZINESS
  • HEADACHES
  • VERTIGO
  • EAR INFECTIONS
  • NAUSEA
  • TMJ
  • NECK PAIN
  • MIGRAINES
  • ANXIETY
  • THROAT ISSUES
  • THYROID PROBLEMS
  • ASTHMA
  • ULCERS
  • NUMBNESS IN ARMS
  • NUMBNESS IN HANDS
  • MENSTRUAL DISORDER
  • HEART DISORDERS
  • STOMACH DISORDERS
  • KIDNEY PROBLEMS
  • MID BACK PAIN
  • IRRITABLE BOWEL
  • SCIATICA
  • NUMBNESS IN LEGS
  • NUMBNESS IN FEET
  • LOW BACK PAIN
  • HIP PAIN
  • LEG PAIN
  • LIVER DISEASE
  • SHOULDER PAIN
  • CHRONIC FATIGUE
  • LUPUS
  • FIBROMYALGIA
  • CHEST PAIN
  • ARM PAIN
  • ADD/ADHD
  • KNEE PAIN
  • NERVOUSNESS
  • EPILEPSY
  • DISC PROBLEMS
  • INFERTILITY
  • GASTRIC REFLUX
  • BLADDER PROBLEMS
  • CHRONIC SINUS
  • NONE
• OTHER PROBLEMS:
  Separate with commas.
• Current conditions you have now / have had*
  • STROKE
  • CANCER
  • HEART DISEASE
  • SPINAL SURGERY
  • SEIZURES
  • SPINAL BONE FRACTURE
  • SCOLIOSIS
  • DIABETES
  • NONE

• 6. Social History

• Smoking*
  • NONE
  • Cigars
  • Pipe
  • Cigarettes
• How Often?
  • Daily
  • Weekends
  • Occasionally
  • Never
• Exercise | How often?*
  • Daily
  • Weekends
  • Occasionally
  • Never

• How does your present problem affect the following:

• Hobbies - Recreational Activities - Exercise
• What daily activities are being restricted by your current health problems?*
  • Carrying/Lifting Groceries
  • Sitting to Standing
  • Climbing Stairs
  • Pet Care
  • Yard Work
  • Laundry
  • Driving
  • Extended Computer Use
  • Garbage
  • Lifting Children
  • Walking
  • Dishes
  • Reading/Concentration
  • Sweeping/Vacuuming
  • Dressing
  • Shaving
  • Bathing
  • Sexual Activities
  • Sleep
  • Static Sitting
  • Static Standing
  • NONE

• Please select the number that best describes the question being asked.

  Select pain level for each issue you are experiencing on a scale for 0 - 10. With 0 being "No Pain" and 10 being "Worst Possible Pain".
• Issue 1*
• What is your pain RIGHT NOW?*
  012345678910
• What is your TYPICAL or AVERAGE pain?*
  012345678910
• What is your pain level AT ITS BEST (How close to "0" does your pain get at it's best)?*
  012345678910
• What is your pain level AT ITS WORST (How close to "10" does your pain get at it's worst)?*
  012345678910
• Issue 2
• What is your pain RIGHT NOW?
  012345678910
• What is your TYPICAL or AVERAGE pain?
  012345678910
• What is your pain level AT ITS BEST (How close to "0" does your pain get at it's best)?
  012345678910
• What is your pain level AT ITS WORST (How close to "10" does your pain get at it's worst)?
  012345678910
• Issue 3
• What is your pain RIGHT NOW?
  012345678910
• What is your TYPICAL or AVERAGE pain?
  012345678910
• What is your pain level AT ITS BEST (How close to "0" does your pain get at it's best)?
  012345678910
• What is your pain level AT ITS WORST (How close to "10" does your pain get at it's worst)?
  012345678910
• Issue 4
• What is your pain RIGHT NOW?
  012345678910
• What is your TYPICAL or AVERAGE pain?
  012345678910
• What is your pain level AT ITS BEST (How close to "0" does your pain get at it's best)?
  012345678910
• What is your pain level AT ITS WORST (How close to "10" does your pain get at it's worst)?
  012345678910
• Issue 5
• What is your pain RIGHT NOW?
  012345678910
• What is your TYPICAL or AVERAGE pain?
  012345678910
• What is your pain level AT ITS BEST (How close to "0" does your pain get at it's best)?
  012345678910
• What is your pain level AT ITS WORST (How close to "10" does your pain get at it's worst)?
  012345678910
• Other Comments

• Review Form

  Please go back through this form and ensure that you have filled in ALL relevant information before submitting.
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