New Patient Entrance Forms

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Confidential Patient Health Record Today¡¯s Date:____/_____/________
How did you hear about us? 􀀀 Family ________________ 􀀀 Friend ___________________ 􀀀 Co-Worker _________________
􀀀 Close to home/work 􀀀 Dr. ______________ 􀀀 Yellow pages 􀀀 Drove by 􀀀 Hospital 􀀀 Insurance Plan

Personal Information
Title: 􀀀 Mr. 􀀀 Ms. 􀀀 Mrs. 􀀀 Dr. 􀀀 Rev. 􀀀 Miss 􀀀 Prof. 􀀀 other: __________________________________
Last:__________________________ First:___________________________ Middle: ____________________________
Suffix: 􀀀 Jr 􀀀 Sr 􀀀 II 􀀀 III 􀀀 MD 􀀀 PhD 􀀀 DO 􀀀 Esq 􀀀 PA 􀀀 RN 􀀀 BSN 􀀀 other: _______________________
Birth Date: ____ /____/_______ Age:______ Sex: Male / Female

Primary Language: 􀀀 English 􀀀 French 􀀀 German 􀀀 Spanish 􀀀 other: ______________________________________
Driver¡¯s License #: _________________ State: _____
Blood Type: 􀀀 A positive 􀀀 A negative 􀀀 B positive 􀀀 B negative 􀀀 AB positive 􀀀 AB negative 􀀀 O positive 􀀀 O negative
Race: 􀀀 African American 􀀀 Asian 􀀀 Caucasian 􀀀 Hispanic 􀀀 Multiracial 􀀀 Native American 􀀀 Other: __________________
Marital Status: 􀀀 Single 􀀀 Married 􀀀 Widowed 􀀀 Divorced 􀀀 Separated
Eye Color: 􀀀 blue 􀀀 brown 􀀀 green 􀀀 grey 􀀀 hazel 􀀀 other: __________
Hair Color: 􀀀 black 􀀀 blonde 􀀀 brown 􀀀 gray 􀀀 red 􀀀 white 􀀀 other: __________
Address: ______________________________________________________________________________Apt # ______
City: __________________ State: ______ Zip: _________ Country: __________________ County: _____________
Home Phone: (_______) _______-_________ ext ______ Work Phone: (_______) _______-_________ ext ______
Cell Phone: (_______) _______-_________ ext ______ Fax #: (_______) _______-_________ ext ______
Email Address: _____________________________ Spouses Name: __________________________________
Children (Names and Ages): _________________________________________________________________________
Emergency Contact
Title: 􀀀 Miss 􀀀 Mrs. 􀀀 Ms. 􀀀 Master 􀀀 Mr. 􀀀 Dr. 􀀀 Prof. 􀀀 Rev. 􀀀 other: __________________________________
Last:__________________________ First:___________________________ Middle: ____________________________
Suffix: 􀀀 Jr 􀀀 Sr 􀀀 II 􀀀 III 􀀀 MD 􀀀 PhD 􀀀 DO 􀀀 Esq 􀀀 PA 􀀀 RN 􀀀 BSN 􀀀 other: __________________
Address: ______________________________________________________________________________Apt # ______
City: __________________ State: ______ Zip: _________ Country: __________________ County: _____________
Relationship: 􀀀 Spouse 􀀀 Relative 􀀀 Friend 􀀀 Other ______________________
Email Address: _____________________________
Birth Date: ____ /____/_______ Social Security #: _______-_______-________
Home Phone: (_______) _______-_________ ext ______ Cell Phone: (_______) _______-_________ ext ______
Work Phone: (_______) _______-_________ ext ______ Fax #: (_______) _______-_________ ext ______
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Employment Information
Business Name: ____________________________________________________________________________________
Address: ______________________________________________________________________________Apt # ______
City: __________________ State: ______ Zip: _________ Country: __________________ County: _____________
Phone: (_______) _________-____________ Fax #: (_______) _________-____________
Employer¡¯s Email Address: ___________________________
Occupation/Job Title: __________________________ Job Description ______________________________________
Current Health Condition
Unwanted Condition (Why you are here today?):________________ Use the letters BELOW to indicate the TYPE
and LOCATION of your sensations right now.
____________________________________________________________
PLEASE LABEL ON THE DIAGRAM THE AREA OF DISCOMFORT Key: A=Ache B=Burning N = Numbness
¡ú ¡ú ¡ú ¡ú ¡ú ¡ú ¡ú P=Pins & Needles S=Stabbing
When did this Condition BEGIN? _____/_______/_________
Has it ever occurred before? 􀀀 Yes 􀀀 No. When? ____________
Is the Condition: 􀀀 Auto Related 􀀀 Job Related 􀀀 Home Injury
􀀀 Slip or Fall 􀀀 Lifting 􀀀 Slept Wrong 􀀀 Unknown Cause 􀀀 Other
Explain: ______________________________________________
______________________________________________________
Date of Accident: _________ Time of Accident: ________ am /pm
Condition/Pain STARTED on what Date: _____________________
Do you SUFFER with ANY OTHER Condition than which you
are now consulting us?
______________________________________________________
______________________________________________________
REVIEW OF SYSTEMS -Below is a list of symptoms that may seem unrelated to the purpose of your appointment.
However, these questions must be answered carefully as the problems can affect your overall course of care.
Constitutional: 􀀀 I DENY having or have had any of the symptoms or problems listed below.
􀀀 chills 􀀀 fatigue 􀀀 night sweats 􀀀 weight loss
􀀀 daytime drowsiness 􀀀 fever 􀀀 weight gain
Eyes/Vision: 􀀀 I DENY having any of the symptoms or problems listed below.
􀀀 blindness 􀀀 change in vision 􀀀 field cuts 􀀀 photophobia
􀀀 blurred vision 􀀀 double vision 􀀀 glaucoma 􀀀 tearing
􀀀 cataracts 􀀀 eye pain 􀀀 itching 􀀀 wear glasses/contacts
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Ears, Nose and Throat: 􀀀 I DENY having any of the symptoms or problems listed below.
􀀀 bleeding 􀀀 ear drainage 􀀀 hearing loss 􀀀 nosebleeds 􀀀 sore throat
􀀀 dentures 􀀀 ear pain 􀀀 history of head injury 􀀀 postnasal drip 􀀀 tinnitus
(ringing in ears)
􀀀 difficulty
swallowing
􀀀 fainting 􀀀 hoarseness 􀀀 rhinorrhea
(runny nose)
􀀀 TMJ problems
􀀀 discharge 􀀀 frequent sore throats 􀀀 loss of sense of smell 􀀀 sinus infections
􀀀 dizziness 􀀀 headaches 􀀀 nasal congestion 􀀀 snoring
Respiration: 􀀀 I DENY having any of the symptoms or problems listed below.
􀀀 asthma 􀀀 coughing up blood 􀀀 sputum production
􀀀 cough 􀀀 shortness of breath 􀀀 wheezing
Cardiovascular: 􀀀 I DENY having any of the symptoms or problems listed below.
Gastrointestinal: 􀀀 I DENY having any of the symptoms or problems listed below.
􀀀 abdominal pain 􀀀 diarrhea 􀀀 indigestion 􀀀 abnormal stool
caliber
􀀀 vomiting blood
􀀀 belching 􀀀 difficulty swallowing 􀀀 jaundice 􀀀 abnormal stool color
􀀀 black - tarry stools 􀀀 heartburn 􀀀 nausea 􀀀 abnormal stool consistency
􀀀 constipation 􀀀 hemorrhoids 􀀀 rectal bleeding 􀀀 vomiting
Female: 􀀀 I DENY having any of the symptoms/problems and/or using any of the items listed below.
􀀀 birth control 􀀀 cramps 􀀀 irregular menstruation 􀀀 vaginal bleeding
􀀀 breast lumps/pain 􀀀 frequent urination 􀀀 pregnancy 􀀀 vaginal discharge
􀀀 burning urination 􀀀 hormone therapy 􀀀 urine retention
Male: 􀀀 I DENY having any of the symptoms or problems listed below.
􀀀 burning urination 􀀀 frequent urination 􀀀 prostate problems
􀀀 erectile dysfunction 􀀀 hesitancy/ dribbling 􀀀 urine retention
Endocrine: 􀀀 I DENY having any of the symptoms or problems listed below.
􀀀 cold intolerance 􀀀 excessive hunger 􀀀 goiter 􀀀 unusual hair growth
􀀀 diabetes 􀀀 excessive thirst 􀀀 hair loss 􀀀 voice changes
􀀀 excessive appetite 􀀀 abnormal frequency of urination 􀀀 heat intolerance
Skin: 􀀀 I DENY having any of the symptoms or problems listed below.
􀀀 changes in nail texture 􀀀 hair loss 􀀀 itching 􀀀 skin lesions / ulcers
􀀀 changes in skin color 􀀀 hives 􀀀 paresthesias 􀀀 varicosities
􀀀 hair growth 􀀀 history of skin disorders 􀀀 rash
Nervous System: 􀀀 I DENY having any of the symptoms or problems listed below.
􀀀 dizziness 􀀀 limb weakness 􀀀 numbness 􀀀 slurred speech 􀀀 tremor
􀀀 facial weakness 􀀀 loss of consciousness 􀀀 seizures 􀀀 stress 􀀀 unsteadiness of gait/
loss of balance
􀀀 headache 􀀀 loss of memory 􀀀 sleep disturbance 􀀀 strokes
Psychologic: 􀀀 I DENY having any of the symptoms or problems listed below.
􀀀 anhedonia 􀀀 behavioral change 􀀀 convulsions 􀀀 memory loss
􀀀 angina (chest pain or discomfort) 􀀀 high blood pressure 􀀀 shortness of breath
with exertion or exercise
􀀀 chest pain 􀀀 low blood pressure 􀀀 swelling of legs
􀀀 claudication (leg pain/ache) 􀀀 orthopnea (difficulty breathing lying down) 􀀀 ulcers
􀀀 heart murmur 􀀀 palpitations 􀀀 varicose veins
􀀀 heart problems 􀀀 paroxysmal nocturnal dyspnea
(waking at night w/ shortness of breath)
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􀀀 anxiety 􀀀 bi-polar disorder 􀀀 depression 􀀀 mood change
􀀀 loss or change in appetite 􀀀 confusion 􀀀 insomnia
Allergy: 􀀀 I DENY having any of the symptoms or problems listed below.
􀀀 anaphalaxis 􀀀 itching 􀀀 chronic nasal congestion 􀀀 sneezing
􀀀 food intolerance 􀀀 acute nasal congestion 􀀀 rash
Hematologic: 􀀀 I DENY having any of the symptoms or problems listed below.
􀀀 anemia 􀀀 blood clotting 􀀀 bruising easily 􀀀 lymph node swelling
􀀀 bleeding 􀀀 blood transfusion 􀀀 fatigue
PAST HEALTH HISTORY ¨C Fill out carefully as these problems can affect your overall course of care.
Previous Care for this Same Condition:
􀀀 I have not previously seen a doctor for this condition OR Fill in the information BELOW
Have you seen other doctors for THIS CONDITION? 􀀀 Yes 􀀀 No. If yes, Who? (Name) ______________________
Type of Treatment: ____________________ Were you satisfied with the results of your treatment? 􀀀 Yes 􀀀 No
Explain: _______________________________________________________________________________________
Previous Chiropractic Care: 􀀀 I have not previously seen a Chiropractor OR Fill in the information BELOW.
Doctor¡¯s Name: ________________________ Location: ______________________ Date of Last Visit: ___________
Were you satisfied with your care? 􀀀 Yes 􀀀 No. Why? _________________________________________________
Do you wear any of the following? 􀀀 Heel Lifts 􀀀 Innersoles 􀀀 Arch Supports 􀀀 Orthotics 􀀀 Other____________
For how long? _________________________ Were they prescribed by a doctor? 􀀀 Yes or 􀀀 No.
Current Medication (s): List ANY/ALL medications you are CURRENTLY taking. Be Specific.
Medication Dosage For What Condition? How long have
you been taking this?
Current Vitamins, Herbs, etc: List ANY/ALL non-prescription items you are CURRENTLY taking. Be Specific.
Dosage For What Condition, if any? How long have
you been taking this?
Childhood Illness (es): LIST all health conditions. CIRCLE all CURRENT conditions.
􀀀 ADD 􀀀 chicken pox 􀀀 headaches 􀀀 scoliosis
􀀀 atopic dermatitis (eczema) 􀀀 crohn¡¯s/colitis 􀀀 hepatitis 􀀀 seizure disorder
􀀀 allergies/hayfever 􀀀 depression 􀀀 HIV 􀀀 sickle cell anemia
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􀀀 anemia 􀀀 diabetes 􀀀 measles 􀀀 spina bifida
􀀀 asthma 􀀀 ear infections 􀀀 mumps 􀀀 other:
􀀀 bedwetting 􀀀 fetal drug exposure 􀀀 psoriasis
􀀀 cerebral palsy 􀀀 food allergies (list below) 􀀀 rash
Do you believe that the Adult Illnesses listed below are contributory to your CURRENT Condition? 􀀀 yes or 􀀀 no.
Adult Illness (es): LIST all health conditions. CIRCLE all CURRENT conditions.
􀀀 ADD 􀀀 cystic kidney disease 􀀀 hypertension 􀀀 psychiatric problems
􀀀 alzheimers 􀀀 depression 􀀀 influenzal pneumonia 􀀀 scoliosis
􀀀 anemia 􀀀 diabetes (insulin dep) 􀀀 liver disease 􀀀 seizures
􀀀 arthritis 􀀀 diabetes (non insulin) 􀀀 lung disease 􀀀 shingles
􀀀 asthma 􀀀 eczema 􀀀 lupus erythema (discoid) 􀀀 past history of similar symptoms
􀀀 cancer 􀀀 emphysema 􀀀 lupus erythema (systemic) 􀀀 STD¡¯s (unspecified)
􀀀 cerebral palsy 􀀀 eye problems 􀀀 multiple sclerosis 􀀀 suicide attempt(s)
􀀀 chicken pox 􀀀 fibromyalgia 􀀀 parkinson¡¯s disease 􀀀 thyroid problems
􀀀 crohn¡¯s/colitis 􀀀 heart disease 􀀀 unspecified pleural effusion 􀀀 vertigo
􀀀 CRPS (RSD) 􀀀 hepatitis 􀀀 pneumonia 􀀀 other:
􀀀 CVA (stroke) 􀀀 HIV 􀀀 psoriasis
Surgery (ies): LIST All Surgical Procedures. Write the DATE of the Procedure immediately afterward.
􀀀 angioplasty 􀀀 cosmetic 􀀀 hysterectomy 􀀀 pacemaker insertion
􀀀 appendectomy 􀀀 D & C 􀀀 joint reconstruction 􀀀 rotator cuff
􀀀 caesarian section 􀀀 dental sugery 􀀀 joint replacement 􀀀 spinal fusion
􀀀 cardic catheterization 􀀀 gall bladder 􀀀 knee repair 􀀀 tonsilectomy
􀀀 carpal tunnel repair 􀀀 hemorrhoidectomy 􀀀 laminectomy 􀀀 other:
􀀀 coronary artery bypass 􀀀 hernia repair 􀀀 mastectomy
Females ONLY: Ob/Gyn Mark all that apply below.
If you have been pregnant in the past, please fill in the appropriate information below.
_____ Number of complicated pregnancies _____ Number of uncomplicated pregnancies
_____Number of C-sections _____ Number of vaginal deliveries
_____ Number of miscarriages _____ Number of terminated pregnancies
I¡­ 􀀀 am currently pregnant 􀀀 am NOT currently pregnant
Menstrual History.
I¡­ 􀀀 currently have menses. 􀀀 currently DO NOT have menses.
My menses¡­ 􀀀 are regular. 􀀀 are NOT regular.
_____ Age of first menses _____ Age when metaphase began
Date of last menses: ______/______/________
Injury (ies): Mark or List All Injuries. Write the DATE of the Injury immediately afterward.
􀀀 back injury 􀀀 head injury (loss of consciousness) 􀀀 motor vehicle accident
􀀀 broken bones 􀀀 head injury (no loss of consciousness) 􀀀 soft tissue injury (mild)
􀀀 disability (ies) 􀀀 industrial accident 􀀀 soft tissue injury (moderate)
􀀀 fall (severe) 􀀀 joint injury 􀀀 soft tissue injury (severe)
􀀀 fracture 􀀀 laceration (severe) 􀀀 other:
Immunizations: Please list the date(s)next to the immunization, if known.
􀀀 adenovirus 􀀀 hepatitis C 􀀀 pertussis 􀀀 tuberculosis
􀀀 anthrax 􀀀 influenza 􀀀 pneumococcal 􀀀 tularemia
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􀀀 botulism 􀀀 IPV (polio) 􀀀 pneumovax 􀀀 typhoid
􀀀 diphtheria 􀀀 Japanese encephalitis 􀀀 PPD (mantoux test- TB) 􀀀 varivax (chicken pox)
􀀀 DTaP (diphtheria,
tetanus, pertussis)
􀀀 lyme disease 􀀀 rabies 􀀀 whooping cough (pertussis)
􀀀 flu 􀀀 measles 􀀀 rotavirus 􀀀 yellow fever
􀀀 haemophilus B 􀀀 meningococcal 􀀀 rubella 􀀀 other:
􀀀 hepatitis A 􀀀 MMR 􀀀 smallpox
􀀀 hepatitis B 􀀀 mumps 􀀀 tetanus
Non-Drug Allergies: Mark all that apply below.
􀀀 adhesive tape 􀀀 eggs 􀀀 newsprint 􀀀 shellfish
􀀀 animals 􀀀 feathers 􀀀 nuts 􀀀 smoke
􀀀 bee sting 􀀀 food coloring 􀀀 peanuts 􀀀 soap
􀀀 chocolate 􀀀 latex 􀀀 perfumes 􀀀 soy
􀀀 dairy 􀀀 mold 􀀀 pollen 􀀀 wheat
􀀀 other:
Label the NUMBER (#) of the TYPE of reaction you have to EACH allergy immediately AFTER the allergy above:
1. angioedema 3. GI disturbance 5. joint pain 7. shortness of breath
2. anaphylaxis 4. headache 6. rash 8. unspecified reaction
Family History: Mark all that apply below. List any specific conditions past or present after has/had:
general family 􀀀 alive 􀀀 deceased 􀀀 normally developed 􀀀 no significant disease 􀀀 has/had:______________________
father 􀀀 alive 􀀀 deceased 􀀀 normally developed 􀀀 no significant disease 􀀀 has/had:______________________
mother 􀀀 alive 􀀀 deceased 􀀀 normally developed 􀀀 no significant disease 􀀀 has/had:______________________
paternal grandfather 􀀀 alive 􀀀 deceased 􀀀 normally developed 􀀀 no significant disease 􀀀 has/had:______________________
paternal grandmother 􀀀 alive 􀀀 deceased 􀀀 normally developed 􀀀 no significant disease 􀀀 has/had:______________________
maternal grandfather 􀀀 alive 􀀀 deceased 􀀀 normally developed 􀀀 no significant disease 􀀀 has/had:______________________
maternal grandmother 􀀀 alive 􀀀 deceased 􀀀 normally developed 􀀀 no significant disease 􀀀 has/had:______________________
son (s) 􀀀 alive 􀀀 deceased 􀀀 normally developed 􀀀 no significant disease 􀀀 has/had:______________________
daughter(s) 􀀀 alive 􀀀 deceased 􀀀 normally developed 􀀀 no significant disease 􀀀 has/had: _____________________
brother(s) 􀀀 alive 􀀀 deceased 􀀀 normally developed 􀀀 no significant disease 􀀀 has/had: _____________________
sister(s) 􀀀 alive 􀀀 deceased 􀀀 normally developed 􀀀 no significant disease 􀀀 has/had:______________________
Social History: Mark all that apply below.
Alcohol: 􀀀 do not drink alcohol 􀀀 social consumption only 􀀀 drink the following regularly (mark below)
􀀀 beer 􀀀 liquor 􀀀 wine; quantity of ________ oz./glasses per 􀀀 day 􀀀 week 􀀀 month
My Dietary Intake consists mainly of the following: (mark all that apply)
􀀀 high fat 􀀀 high salt 􀀀 low fiber
􀀀 high fiber 􀀀 low calorie 􀀀 low salt
􀀀 high protein 􀀀 low carbohydrate 􀀀 low sugar
Mark the highest level of Education completed:
􀀀 pre-school 􀀀 high school 􀀀 college 􀀀 doctorate
􀀀 elementary school 􀀀 high school graduate 􀀀 college graduate 􀀀 graduate school
􀀀 middle school 􀀀 GED 􀀀 associates degree 􀀀 graduate degree
􀀀 vocational school 􀀀 high school ¨C incomplete 􀀀 bachelors degree 􀀀 other: ______________
Substance: 􀀀 never used illegal drugs 􀀀 has not used illegal drugs since __________ .
􀀀 never used IV drugs 􀀀 used illegal drugs for ______________ (how long?)
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Tobacco: 􀀀 Do not use tobacco 􀀀 Do not smoke cigars, cigarettes or pipe 􀀀 Live with a smoker 􀀀 Quit smoking
􀀀 Smoke: # ____ per 􀀀 Day 􀀀 Week 􀀀 Month; 􀀀 Chew: #______cans per 􀀀 Day 􀀀 Week 􀀀 Year
Insurance Information:
Who Is Responsible For Your Bill? YOU and¡­ (mark appropriate box(es)) 􀀀 Myself ONLY
􀀀 Spouse 􀀀 Worker¡¯s Comp 􀀀 Auto Insurance 􀀀 Medicare 􀀀 Medicaid 􀀀 Other (be specific):_______________
Personal Health Insurance Carrier: __________________ Health ID Card #: ____________________________
Policy Holder¡¯s Name: _____________________________ Group #: ____________________________________
Policy Holder¡¯s Social Security #: ______-_____-_______ Primary Care Physician: _______________________
Workers Compensation Injury / Auto / Personal Injury:
Have you filed an injury report with your employer? 􀀀Yes 􀀀 No Date:____/____/______Time: _______am/pm
Carrier: _____________________________________________ Policy # _______________________________
Carriers Phone #: (_______) ___________-_______________ Adjuster: ______________________________
Claim #: _____________________________________________
I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand
that the Chiropractic Clinic will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any
amount authorized to be paid directly to the Chiropractic Clinic will be credited to my account upon receipt. However, I clearly understand and agree
that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate
my care or treatment, any fees for professional services rendered me will be immediately due and payable.
I hereby authorize the Doctor to treat my condition as he or she deems appropriate through the use of Chiropractic Health Care, and I give authority for
these procedures to be performed. It is understood and agreed the amount paid the Doctor, for x-rays, is for examination only and the x-ray negative will
remain the property of this office, being on file where they may be seen at any time while a patient of this office. The patient also agrees that he/she is
responsible for all bills incurred at this office.
Patient Print Name: _____________________________ Patient¡¯s Signature: __________________________ Date: ___________
Consent to treat a Minor: _________________________________ Date: ______________
Guardian or Spouse¡¯s Signature of Authorizing Care: __________________________________ Date: ______________
I acknowledge that I have received the Chiropractic Clinic¡¯s Notice of Privacy Practices for protected health information.
Patient Print Name: ____________________________________________ Date: ______________
Patient¡¯s Signature: ____________________________________________ Date: ______________
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