Online Forms

New Patient Health History Form

In order to provide you the best possible care, please complete this form and bring it to your first appointment. All information is strictly CONFIDENTIAL.

Patient Data

* Your email will NOT be shared with any 3rd parties, and is used for occasional office announcements and promotions.

Mailing Address

Current Complaints

Nature of Injury:
Nature of Injury
Have you ever had same condition?
Have you ever had same condition?
Have you ever been under chiropractic care?
Have you ever been under chiropractic care?

Insurance Information

Do you have health insurance?
Do you have health insurance?

* If an auto accident, please provide:

Signatures

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Medical History

Have you been treated for any conditions in the last year?
Have you been treated for any conditions in the last year?
Is there a chance that you are pregnant?
Is there a chance that you are pregnant?
Have you had X-rays taken?
Have you had X-rays taken?

Have you ever

Broken bones?
Broken bones?
Been hospitalized?
Been hospitalized?
Been in an auto accident?
Been in an auto accident?
Had Sprains/Strains?
Had Sprains/Strains?
Been struck unconscious?
Been struck unconscious?
Had surgery?
Had surgery?

Family History

Do you experience pain every day?
Do you experience pain every day?
Do your symptoms interfere with daily life?
Do your symptoms interfere with daily life?
Does pain wake you up at night?
Does pain wake you up at night?
Are your symptoms worse during certain times of the day?
Are your symptoms worse during certain times of the day?
Do changes in weather affect your symptoms?
Do changes in weather affect your symptoms?
Do you wear orthotics?
Do you wear orthotics?
Do you take vitamin supplements?
Do you take vitamin supplements?

Habits

Alcohol
Alcohol
Coffee
Coffee
Tobacco
Tobacco
Drugs
Drugs
Exercise
Exercise
Sleep
Sleep
Appetite
Appetite
Soft Drinks
Soft Drinks
Water
Water
Salty Foods
Salty Foods
Sugary Foods
Sugary Foods
Artificial Sweeteners
Artificial Sweeteners

Have you ever suffered from

Please use the following letters to indicate TYPE and LOCATION of the symptoms you currently are experiencing.

  • A=Ache
  • B=Burning
  • N=Numbness
  • O=Other
  • P=Pins & Needles
  • S=Stabbing
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