New Patient Form New Patient Form Please fill out all blanksDate: MM slash DD slash YYYY Name:* First Middle Last Marriage Status:* Married Single Widow Divorce Birth Date:* MM slash DD slash YYYY Sex:* Male Female Height:*Weight:*Mailing Address:* Street Address City State / Province / Region ZIP / Postal Code Home Phone:*Cell Phone:*Email Address:* Employed By:* Occupation:* Work Phone:*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 MM slash DD slash YYYY 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?* Y N Vitamins* Y N Homeopathic medicines?* Y N List 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? Y N If 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?* Loose Constipation Both if they alternate Approximately 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 Water Filtered City Water Bottle Spring Water or Well Water Distilled Water 18. Do you live close to a freeway or other heavy traffic area?* Y N 19. Do you eat shell fish (shrimp, lobster, crab, scallops, etc.) regularly?* Y N Which?* Do you use aluminum pans?* Y N have you ever used aluminum pans?* Y N Do you use commercial body deodorants that contain aluminum?* Y N 21. How often do you eat :*Chocolate Ice Cream* Popcorn* Spicy foods* Pastries* 22. Do you drink carbonated “soft drinks”* Y N Regular or Artificially sweetened?* Regular Artificially sweetened How many per day?*week?*Do you smoke?* Y N How much?* 24. Do you drink coffee?* Y N Cups per day?*Tea* Y N Cups per day?*Alcohol* Y N beers/week;*glasses of wine/week;*mixed drinks/week.*25. Are you exposed to or in contact with chemicals or fumes in your work environment?* Y N Which ones? 26. Have you been exposed to new carpet, paint, particle board, or a new car recently?* Y N please describe. 27. Please list on the average what you have for major meals and for snacks.*Breakfast: Lunch:* Lunch: Dinner:*Dinner: Snacks:*Snacks: 28.Do you work on computers?* Y N How often and for how long? 29. Please indicate whether you have regular exercise/sports/hobbies.* 30. Have you ever had chiropractic care before?* Y N Did it seem to help you? Y N or to aggravate your condition? Y N 31. Have you ever had x-rays before?* Y N How 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? Y N Which ones? 34. Do you have breast implants or prostheses?* Y N Which ones? CAPTCHA