New Patient Form

Please fill out all blanks
Date:
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 Interview
Patient'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

New Patient Form

Please fill out all blanks

In Case Of Emergency Nearest Relative Not Living With You:

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.