New Patient Form

Past History

Your Personal Primary Care Giver / Physician

Prefix First Last Suffix

Clinic

Have you had previous Chiropractic Care?*

Yes
No

What Chiropractor did you see?

Estimated length of time since last treatment with a Chiropractor?

Date of last treatment?

Have you had similar pain in the past?*

Yes
No

Explain:

Have you been in any car accidents?*

Yes
No

Date of accident

Injuries from accident?

Have you had any bad falls?*

Yes
No

Explain:

List any injuries from falls, accidents, head injuries, broken bones or dislocations? If you have had any, please state what part of your body the injury happened and when it happened (specify left or right side):

Select any of the following that you have had:

What kind of cancer? When?

List any illnesses that run in your family:

Do you take any medication?*

Yes
No

List any medications that you take and what you take them for:

Have you had any Surgeries?*

Yes
No

List any Surgeries that you have had and when you had them:

Are you pregnant or do you think you may be?

Yes
No

Date of last period?

Habits

Do you Exercise?

Yes
No

Type of Exercise?

How much do you Exercise in a week?

Tobacco User?

Yes
No

Former Tobacco User?

Yes
No

Type of Tobacco Used?

Chew
Cigar
Cigarettes

How much tobacco/Day

Alcohol?

Yes
No

Drinks/Week

Coffee?

Yes
No

Cups/Day

Soda?

Yes
No

Cans/Day

High Stress Level?

Yes
No

Reason?

Age

Height

Weight

Is your first appointment scheduled?

If you have not already called to set up an appointment please note what days and times are best for you and our office will call you to confirm an appointment.

Signature

Date

How did you hear about our office?

Whom may we thank for referring you to us?

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Step 1 of 3

Emergency Contact

Symptoms

Past History

Habits