New Patient Intake Form New Patient Intake Form First Name * Middle Name * Last Name * Cell Number Work Number Home Number Patient's Email Guardian Yes No Guardian First Name * Guardian Middle Name * Guardian Last Name * Date SSN Birthday Sex Male Female Trans Relationship Status Single Married Children Address Address Address Address Address Address State Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Address Referral Previous Chiro Employer Address Duties Emergency Contact: First Name Last Name Relationship Phone Email History: Checkboxes Allergies Alcoholism Anemia Anxiety Arteriosclerosis Arthritis Arm pain L | R Asthma Back Pain Breast Lump Bronchitis Bruise Easily Short of Breath Sinus Infection Spinal Curvatures Checkboxes Chest Pain Cold Extremities Constipation Cramps Chemical Dependency Depression Diabetes Digestion Trouble Dizziness Emphysema Epilepsy Eye Pain Tumors Stroke Swelling of Ankles Checkboxes Fatigue Frequent Urination Irregular Menstrual Hernia Hemorrhoids High Blood Pressure High Cholesterol Insomnia Irregular Heartbeat Headache Hot Flashes Kidney Infection Fracture Swollen Joints Thyroid Condition Checkboxes Kidney Stones Loss of Balance Loss of Memory Loss of Smell Loss of Taste Multiple Sclerosis Migraine L | R side Nosebleeds Pacemaker Poor Posture Prostate Trouble Sciatica Ulcers Tuberculosis Stroke Cancer Cancer Describe Primary Complaint When did you first notice it? What were you doing? Where is the symptom? Where does it travel? Checkboxes Sharp Dull Aching Burning Numb Throbbing Radiating Shooting Tingling Cramps Stiffness Swelling Please select your level of pain 1 2 3 4 5 6 7 8 9 10 0 = No Pain / 10 = Worst Pain % of time present with symptoms 50%0%100% What makes it better? What makes it worse? Difficult movements? Sitting Standing Bending Walking Does it interfere with Work Sleep Recreation Daily Routine Other What have you tried for relief? Have you had this symptom before? List additional complaints* in order of severity: Medical History of Family Father Mother Siblings Children Preferred Method of Communication Email Phone Call Text Mail Preferred Language Smoking Status Everyday Smoker Occasional Smoker Former Smoker NeverSmoked Alcohol Status Everyday Drinker Occasional Drinker Former Drinker Never Drank Surgeries or Injuries: Medications/Purpose: Allergic Reactions to Medicine or Food: Insurance Company Company 1 Company 2 Subscriber’s Name Birthdate of Subscriber SS# Accident Information Is this from an Auto Accident or Work Comp or other injury? Yes No Date of Injury Attorney name To Whom have you reported this accident? If you are human, leave this field blank. Submit Δ
