New Patient Intake Form Patient Intake Form Please fill out this form and we will get in touch with you shortly. Step 1 of 9 - Patient Data 0% Patient DataFirst and Last Name*FirstLastEmail*Referred ByFirstLastReferral Source--MotherFatherSonDaughterAuntUncleWifeHusbandOther RelativeFriendNeighborColleagueFitness TrainerYoga InstructorCoachBearsCubsSister in-lawBrother in-lawFamily DoctorPhysical TherapistOrthopedicPodiatristOther PhysicianEvent Patient Communication DataAddress*Street AddressCityZIP / Postal CodeState*--AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificHome Phone*Mobile PhoneWork PhoneExtensionPreferred Method of CommunicationMobile NumberHome NumberWork NumberEmailMailText Patient DemographicsAge*Birth Date*Marital Status*MarriedSingleDomestic PartnerOccupationParent/Guardian NameFirstLastParent/Guardian Phone Emergency ContactEmergency Contact Name*FirstLastEmergency Contact Phone*Relationship to Contact Reason for VisitPlease describe the reason for the visitIf this complaint is due to an injury, what is the nature of the injuryAutomotiveWorkers CompPersonal InjurySports/Activity RelatedDate of InjuryLocation of Symptoms (check all that apply)HeadNeckBackShoulderElbowHand/wristHipLegKneeAnkleFootDate Symptoms AppearedHave you ever had the same condition?YesNoIf YES, When?List other practitioners seen for this injury/conditionHave you ever been under chiropractic care?YesNoIf YES, please describe Insurance InformationName of party responsible for payment*FirstLastPhone of party responsible for payment*Do you have health insurance?*YesNoName of insurance company*Primary insured Date Of BirthIf auto accident, workers compensation, personal injury, please provide:Insurance Company NameContact PersonFirstLastContact PhoneClaim NumberClaim Address Medical HistoryHave you been treated for any conditions in the last year?YesNoIf YES, please describeDate of last physical examIs there a chance that you are pregnant?YesNoHave you had x-rays taken?YesNoIf YES, Where?What medications are you taking and for what conditions? (Please list dosage and amounts, etc)What vitamins, minerals, or herbs do you currently take? (Please list for what conditions, dosage, and frequency)Have You Ever:Broken Bones?YesNoBriefly ExplainBeen Hospitalized?YesNoBriefly ExplainBeen in an Auto Accident?YesNoBriefly ExplainHad Sprains/Strains?YesNoBriefly ExplainBeen Struck Unconscious?YesNoBriefly ExplainHad Surgery?YesNoBriefly Explain Family HistoryFamily members - Present and past health conditions (Example: heart disease, cancer, diabetes, arthritis, etc) General HealthDo you experience pain every day?YesNoDo your symptoms interfere with daily life?YesNoDoes pain wake you up at night?YesNoAre your symptoms worse during certain times of the day?YesNoDo you wear orthotics?YesNoWhat activities aggrevate your symptoms?AlcoholNoneLightModerateHeavyCoffeeNoneLightModerateHeavyTobaccoNoneLightModerateHeavyDrugsNoneLightModerateHeavyExerciseNoneLightModerateHeavySleepNoneLightModerateHeavyAppetiteNoneLightModerateHeavySoft DrinksNoneLightModerateHeavyWaterNoneLightModerateHeavySalty FoodsNoneLightModerateHeavySugary FoodsNoneLightModerateHeavyArtificial SweetnersNoneLightModerateHeavyHave you ever suffered from:AlcoholismAllergiesAnemiaArteriosclerosisArthritisAsthmaBack PainBreast LumpBronchitisBruise EasilyCancerChest Pain/ConditionsCold ExtremitiesConstipationCrampsDepressionDiabetesDigestion ProblemsDizzinessEars RingExcessive MenstruationEye Pain or DifficultyFatigueFrequent UrinationHeadacheHemorrhoidsHigh Blood PressureHot FlashesIrregular Heart BeatIrregular CycleKidney InfectionKidney StonesLoss of BalanceLoss of MemoryLoss of SmellLoss of TasteNeck Pain or StiffnessNervousnessNosebleedsPacemakerPolioPoor PostureProstate TroubleSciaticaShortness of BreathSinus InfectionSleep Problems of InsomniaSpinal CurvaturesStrokeSwelling of AnklesSwollen JointsThyroid ConditionsTuberculosisUlcersVaricose VeinsVenereal DiseaseOthers Not Listed?NameThis field is for validation purposes and should be left unchanged.