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Schedule Appointment
Home
About
Testimonials
New Patients
Online Intake Form
Services
Health Education
Contact Us
Schedule Appointment
New Patient Form
New Patient Form
Date
Date Format: MM slash DD slash YYYY
Name
Preferred Name
Address
Street Address
City
State
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Texas
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West Virginia
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Home Phone
Cell Phone
Email
SS #
Birthdate
Age
Occupation
Employer
Is it okay to contact you at work?
Yes
No
Work Phone #
Marital Status
Single
Married
Separated
Divorced
Widowed
Spouse's Name
Spouse's Phone #
Children's Names and Ages
Do you have pets?
Yes
No
Please tell us what kind of pet(s) you own
Favorite hobbies or interests
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone #
What Brings You Here?
Have you ever had chiropractic care before?
Yes
No
Please tell us who provided your care
Provider's Phone #
Were you pleased with your care?
Yes
No
How did you find out about our office?
Is this appointment related to
work
sports
auto
personal injury
When did the incident occur?
Date Format: MM slash DD slash YYYY
Attorney (if applicable)
Attorney's Phone #
Are you receiving care from other health professionals?
Yes
No
Please tell us who they are and their specialty
Please list any drugs or medications you are taking
Please list any vitamins/herbs/homeopathics/other you are taking
Are you pregnant?
Yes
No
What month?
Current Health
What are your pressing health concerns?
How long have you had these concerns?
Is it
getting worse
improving
intermittent
constant
can't say
Where is the problem? Please name the approximate area and if it is on your front or back
Do you have
pain
numbness
tingling
aches
Is your pain
sharp
dull
throbbing
constant
intermittent
Are your symptoms affected by
sitting
standing
walking
bending
lying down
weather
Do you feel
cramps
burning
stiffness
swelling
Do your symptoms interfere with
work
sleep
daily activities
play
Please rate the severity of your symptoms (1 least, 10 most)
1
2
3
4
5
6
7
8
9
10
Health History
Do you have, or previously had, any of the following? (please check all that apply)
pneumonia
mumps
influenza
rheumatic fever
smallpox
pleurisy
polio
chickenpox
thyroid disease
diabetes
epilepsy
cancer
depression
whooping cough
anemia
eczema
measles
arthritis
heart disease
rashes
colitis
stroke
allergies
Please describe your allergies
If you have ever been diagnosed with another disease or condition, please describe
Do you drink
coffee
tea
alcohol
Do you use
cigarettes
recreational drugs
artificial sweeteners
sugar
Have you ever suffered from (please check all that apply)
neck pain
difficulty breathing
discolored urine
low back pain
stuffy nose
gas/bloating after meals
headache
fainting
heartburn
migraines
weight loss
irritable bowel
arm pain/tingling
poor appetite
black or bloody stools
shoulder pain
excessive appetite
constipation
hand pain/tingling
nervousness
hemorrhoids
leg pain/tingling
confusion
liver problems
jaw pain
depression
paralysis
chest pain
dental problems
numbness
lung problems
excessive thirst
fatigue
heart problems
frequent nausea
dizziness
abnormal blood pressure
prostate problem
loss of sleep
irregular heartbeat
breast pain/lump
difficulty hearing
ankle swelling
cramps
ear pain
cold extremities
painful urination
blurred vision
bladder trouble
vision problems
excessive urination
other
Describe your symptoms
If applicable, date of last menstrual period
Past injuries can affect present health (please check all that apply)
falls/accidents
head injuries
fights
surgery
sports injuries
broken bones
dislocations
spinal tap
knocked unconscious
traction
use(d) a cane or walker
extensive dental work
dental applications
other
If yes to any of the above, please describe
What Do You Know About Chiropractic?
In your own words, what do chiropractors do?
Do you know what a subluxation is?
Yes
No
Please describe what a subluxation is
Do any friends or relatives see chiropractors?
Yes
No
Do they use chiropractic for
health maintenance/optimization
health problems
both
Are you seeking chiropractic for
health maintenance/optimization
health problems
both
What would you like to gain from chiropractic care?
Are there other health concerns or anything else you'd like us to know about you?
Yes
No
Please tell us about your concerns
Financial Responsibility
Who is responsible for payment?
How will you pay for your care?
Cash
Check
Credit Card
Credit card #
Expiration Date
Insurance co.
Insurance Phone #
ID #
Group #
Subscriber's name
Subscriber's Phone #
Relation
Subscriber's employer
Subscriber's SS #
Subscriber's birthdate
The above is accurate to the best of my knowledge
*
I agree
Date
*
Date Format: MM slash DD slash YYYY
I, parent/guardian, give permission for minor's care
I agree
Date
Date Format: MM slash DD slash YYYY
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