Welcome New PatientsNew Patient Form - AdultNameAddressCityStateMake a SelectionAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code*PhoneEmail*Date of BirthGenderHeightWeightMarital StatusNumber of ChildrenEmployerEmployer AddressEmployer Phone NumberJob PositionAbout your SpouseNameSpouse Date of BirthSpouse EmployerSpouse Job TitleHealth LifestyleDo you smoke? Yes NoDo you drink alcohol? Yes NoDo you drink caffine? Yes NoDo you exercise regularly? Yes NoChiropractic ExperienceDid Anyone refer you?Have you been adjusted before? Yes NoIf yes, reason for adjustment.Dr. NameApproximate date of last visitReason for VisitDescribe the reason for this visitWhat is the cause of condition?When did it begin?Has the condition: Gotten worse Stayed the same Come and goneRate your pain today, 0-10012345678910Does this condition interfere with: work sleep daily routine otherIf other, please explain.Has this condition occurred before? Yes NoIf yes, please explain.What treatments have you tried for this?Has you seen a doctor for this condition? Yes NoDr. NameType of treatmentDid it help? Yes NoMedicationsWhich apply? cholesterol meds stimulants tranquilizers muscle relaxers blood pressure meds blood thinners pain killers insulin vitamins & supplementsWomen OnlyAre you pregnant? Yes NoDue Date:Are you nursing? Yes NoAre you taking birth control? Yes NoDo you have painful periods? Yes NoDo you have irregular periods? Yes NoDo you have breast implants? Yes NoHealth ConditionsCheck all that apply headaches difficulty breathing heart surgery high blood pressure digestive problems chemotherapy heart attack neck pain thyroid problems sinus problems tuberculosis diabetes sore throat migraines allergies fatigue head colds vision problems hearing problems congestion bronchitis ulcers gastritis constipation diarrhea gas pain bladder problems loss of sleep asthma heptatis kidney problems sinus problems numbness pain in arms legs shingles low blood pressure rheumatic fever ulcers/scolitis arthritis dizziness pain between shoulders radiating arm pain hand / finger numbness heart conditions middle back pain difficulty concentrating low back pain difficulty concentrating low back pain difficulty breathing gallbladder problems stomach problems kidney problems colitis pain or numbness in legs irritable bowel reproductive problemsWould you like to receive text reminders?* yes noPeople see Chiropractors for a variety of reasons. Some go for relief of pain, some to correct the cause of pain, and others for the correction of whatever is malfunctioning in the body. Your doctor will weigh your needs and desires when recommending your care you desire.* Relief Care- pain relief Corrective Care- correct and relief Comprehensive Care- wellness
