New Patient Form

Initial Patient Paperwork

    NEW PATIENT PAPERWORK

    Patient Name (required)

    Patient's Email (required)
    (Or guardian's email if patient is a minor) *Email is required because we will send you your scan and evaluation results*

    Patient's Cell Phone # (required)
    (Or guardian's cell if patient is a minor)

    Patient's Address (required)

    Patient's Zip Code (required)

    Birthdate (required)

    Patient Age (required)

    Patient Gender (required)

    Patient Marital Status (required)

    Do You Have Children? (required)

    Occupation Status: (required)

    Employer (required)
    (If not employed, put N/A)

    Emergency Contact Name (required)

    Emergency Contact Phone 1 (required)

    Emergency Contact Phone 2

    Emergency Contact Employer (required)

    How were you referred to our office? (required)

    PURPOSE OF THIS VISIT

    Is this purpose related to an auto accident or work injury? (required)

    Main Reason for this visit(required)

    When did this condition begin? (required)

    Did it begin gradually, suddenly or progress over time? (required)

    What activities aggravate your symptoms? (required)

    Is there anything, which has relieved your symptoms? (required)

    Type of Pain (required)
    Select All That Apply

    Does the Pain Radiate into your: (required)

    Is this condition getting worse? (required)

    How often do you experience these symptoms throughout the day? (required)

    Does complaint(s) interfere with: (required)

    Have you been seen for this condition? (required)

    SYMPTOMS QUESTIONNAIRE

    Please select symptoms you're experiencing. (required)
    This section is focused on misalignment of the neck region.

    Please select symptoms you're experiencing. (required)
    This section is focused on misalignment of the mid-back region.

    Please select symptoms you're experiencing. (required)
    This section is focused on misalignment of the low back region.

    Please select symptoms you're experiencing. (required)
    This section is focused on misalignment of the pelvis.

    EXPERIENCE WITH CHIROPRACTIC CARE

    Have you seen a chiropractor before? (required)

    Did you know posture determines your health? (required)

    Are you aware of any poor posture habits? (required)

    Are you aware of any poor posture habits in your spouse or children? (required)

    HEALTH LIFESTYLE

    Do you exercise (required)

    Do you smoke? (required)

    Do you drink alcohol? (required)

    Do you drink coffee? (required)

    Do you take any health supplements (vitamins, minerals, herbs, etc.)? (required)

    Please list any health conditions not mentioned above: (required)
    *Put "N/A" if not applicable

    Please list any medications you are currently taking and their purpose: (required)
    *Put "N/A" if not applicable

    Please list all past surgeries: (required)
    *Put "N/A" if not applicable

    Please list all previous accidents and falls: (required)
    *Put "N/A" if not applicable

    HEALTH INSURANCE

    Will you be using health insurance for your chiropractic care? (required)

    Name of Insurance Company (required)
    (If Not Using Insurance, Please Put "N/A")

    Insured Persons Name (required)
    (If Not Using Insurance, Please Put "N/A")

    Insured Person's Address (required)
    (If Not Using Insurance, Please Put "N/A")

    Insured Person's Zip Code (required)
    (If Not Using Insurance, Please Put "N/A")

    Insured Person's Birthdate (required)
    (If Not Using Insurance, Please put todays date)

    Insurance ID Number (required)
    (If Not Using Insurance, Please Put "N/A")

    Insurance Group Number (required)
    (If Not Using Insurance, Please Put "N/A")

    *Before you Click The Button Below to Submit the form, please be sure you have filled out all Required fields above.

    - If you have completed the form correctly, after you click the button below you will be directed to a "Thank You" page.

    - If you click the button below and you remain on this form, it means you have failed to complete a required field.
    (If So, Please review the form and complete the incomplete fields (indicated in red)”

    Please Confirm You Are Human


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