New Patient Form New Patient Form Please fill out all blanksDate: Name:* First Middle Last Marriage Status:*MarriedSingleWidowDivorceBirth Date:* Sex:*MaleFemaleHeight:*Weight:*Mailing Address:* Street Address City State / Province / Region ZIP / Postal Code Home Phone:*Cell Phone:*Email Address:* Employed By:*Occupation:*Work Phone:*Social Security No:Spouse: First Middle Last Spouse Employed By:Occupation:Business Phone:In Case Of Emergency Nearest Relative Not Living With You:Name*Address*Phone*Referred By:*We do not file insurance in our office. We will provide you with a super-bill so you can submit it to your insurance company and get reimbursement according to your policy.Initial Patient InterviewPatient's Name*Date 1. What is the principal complaint for which you are seeking my care?*2. List in order in severity (most severe first) any and ALL health problems which bother you.*3. List any chronic health problems you used to have but which appear to be resolved.*And any present problems which you have simply accepted as part of life, due to the fact that you can't see any way they'll leave.*4. Other doctors seen for above conditions MD DC Lic. Ac. DO DDS Other Name(s) of Doctor(s)*5. List any accidents of injuries you have had, and approximately when they occurred.*6. List any surgeries you have had ( including in-office procedures) giving dates where possible.*7. List any prescription medications or over-the-counter (OTC) drugs you have taken for any length of time (eg. TUMS, Tylenol, Mylanta, etc.)*8. List any prescription medications or OTC drugs you presently take.*9. Do you take herbs?*YNVitamins*YNHomeopathic medicines?*YNList the supplements that you are currently taking.*10. Do you feel you have menstrual or menopausal problems? Describe.11. Do you now or have you in the past taken birth control pills?YNIf so, when, and for how long?12. How would you rate your own digestion (tolerance to foods, occurrence of what seem to be allergies to foods, etc.)*13. How would you describe your elimination, that is: Do you frequently experience loose stools or constipation?*LooseConstipationBoth if they alternateApproximately how many times?*If not daily, how often?*Please state any other relevant comments:14. In your own estimation, how do your kidneys and bladder function?*15. Do you have weak or sensitive lungs?*16. Do you or members of your family have history of heart problems?*17. What type of water do you primarily drink?*City WaterFiltered City WaterBottle Spring Water or Well WaterDistilled Water18. Do you live close to a freeway or other heavy traffic area?*YN19. Do you eat shell fish (shrimp, lobster, crab, scallops, etc.) regularly?*YNWhich?*Do you use aluminum pans?*YNhave you ever used aluminum pans?*YNDo you use commercial body deodorants that contain aluminum?*YN21. How often do you eat :*ChocolateIce Cream*Popcorn*Spicy foods*Pastries*22. Do you drink carbonated “soft drinks”*YNRegular or Artificially sweetened?*RegularArtificially sweetenedHow many per day?*week?*Do you smoke?*YNHow much?*24. Do you drink coffee?*YNCups per day?*Tea*YNCups per day?*Alcohol*YNbeers/week;*glasses of wine/week;*mixed drinks/week.*25. Are you exposed to or in contact with chemicals or fumes in your work environment?*YNWhich ones?26. Have you been exposed to new carpet, paint, particle board, or a new car recently?*YNplease describe.27. Please list on the average what you have for major meals and for snacks.*Breakfast:* Lunch:*Dinner:*Snacks:28.Do you work on computers?*YNHow often and for how long?29. Please indicate whether you have regular exercise/sports/hobbies.*30. Have you ever had chiropractic care before?*YNDid it seem to help you?YNor to aggravate your condition?YN31. Have you ever had x-rays before?*YNHow long ago, and for what?32. When is the last time you had lab work performed, and for what?*33. (CONFIDENTIAL- WILLNOT BE RELEASED WITH MEDICAL RECORDS)*Have you ever used recreational drugs?YNWhich ones?34. Do you have breast implants or prostheses?*YNWhich ones?