New Patient Information Form A full patient history and individual health record.First Name(Required)Middle NameLast Name(Required)Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender Male Female OtherHome PhoneCell PhoneWork PhoneSocial Security #Simply enter the 9 numbers.Email Marital StatusSingleMarriedDivorcedWidowedOtherSpouse's Name# of ChildrenHeight in Feet123456789Inches01234567891011Weight (lbs.)Emergency ContactEmergency Contact Name First Last Phone #RelationshipAbout Your ConditionWhat is the purpose of your visit?Chronic DiscomfortConsultationInjuryNew ConditionSecond opinionWhat is the reason for this visit?Auto accident/pedestrian (job related)Auto accident/pedestrian (personal)Chronic or acute painHome injuryJob-related (but not auto-related)Slip and fall (away from home)Sports injuryWellnessOTHERWhen did this condition begin? MM slash DD slash YYYY Date of Scheduled Appointment MM slash DD slash YYYY How long have you had this condition?5 days or lessmore than 5 days but less than 30 daysmore than 5 days but less than 30 daysWhat caused this condition?Of unknown originAfter a fallAfter a long driveAfter a long flightAfter a poor night's sleepAfter a slipAfter lifting an objectAfter reaching or overarchingAfter performing household choresAfter performing yard workAfter sitting in one place for too longAssociated with prolonged or chronic illnessOTHERIs there Head Discomfort? Front of head Right side of head Back of head Left side of headIs there Neck Discomfort? Front of neck Right side of neck Back of neck Left side of neckIs there Back Discomfort? Right mid back Central mid back Left mid back Right low back Central low back Left low backIs there Trunk Discomfort? Abdomen Back of ribs Chest Right side of ribs Front of ribs Left side of ribsLower Extremity Discomfort? Front of right lower leg Front of left lower leg Rear of right lower leg Rear of left lower leg Front of right hip Front of left hip Rear of right hip Rear of left hip Front of right thigh Front of right knee Rear of right thigh Rear of right knee Front of left thigh Front of left knee Rear of left thigh Rear of left knee Front of right leg Front of right ankle Rear of right leg Rear of right ankle Front of left leg Front of left ankle Rear of left leg Rear of left ankle Top of right foot Top of left foot Bottom of right foot Bottom of left foot Right side of right foot Right side of left foot Left side of right foot Left side of left foot OTHERUpper Extremity Discomfort? Front of right upper extremity Front of left upper extremity Rear of right upper extremity Rear of left upper extremity Front of right shoulder Front of left shoulder Rear of right shoulder Rear of left shoulder Front of right upper arm Front of left upper arm Rear of right upper arm Rear of left upper arm Front of right elbow Front of left elbow Rear of right elbow Rear of left elbow Front of right wrist Front of left wrist Rear of right wrist Rear of left wrist Front of right hand Front of left hand Rear of right hand Rear of left handLower Extremity Discomfort? Aching Sharp Annoying Shock-like Burning Shooting Deep Stabbing Diffuse Stiffness Dull Throbbing Heavy Tightness Intolerable Tingling Pulling OTHERDoes the discomfort radiate/travel? YES NODescribe the onset of the discomfort. Choose only one. Gradual Insidious Recent Spontaneous Sudden Traumatic UnknownDescribe the intensity of the discomfort. Choose only one. Mild Mild to moderate Moderate Moderate to severe SevereRate the severity of your discomfort on a scale of 1-10 where 1 is the least severe and 10 is the most severe. 1 2 3 4 5 6 7 8 9 10How often do you feel this discomfort? Choose only one. Constant Frequent Intermittent On and off Random RecurringHow has this complaint changed since the onset? Improved Stayed the same WorsenedWhat activity is most significantly affected by this discomfort?EmploymentHomemakingLiftingPersonal care (washing, dressing, etc.)SittingSleepingSocial lifeStandingTraveling and/or drivingWalkingWhat aggravates this condition? Choose all that apply. Almost any movement Athletic activity and/or exercise Bathing Bending Caring for family Carrying Changing positions Climbing stairs Computer use Concentrating Cooking Coughing and/or sneezing Daily child or pet care Driving Eating Falling or staying asleep Getting in or out of car Getting out of bed Getting up from lying down Getting up from sitting Grocery shopping Household chores Lifting Looking over shoulder Love life Lying down Pulling Pushing Reaching Reading Repetitive motions Resting Running Self care (dressing, bathing, etc.) Shaving Sitting Squatting Standing Stress Stretching Talking on telephone Turning Twisting Unknown Walking Working Yard work OTHERWhat improves this condition? Choose all that apply. Nothing Chiropractic adjustment Cold packs Exercise Heat packs Massage Over-the-counter medications Physical therapy Prescription medication Re-direct attention Rest Stretching Work OTHERWhat treatment have you received for this condition up to now? None Acupuncture Chiropractic care Craniosacral therapy Homeopathic medicine Hypnosis Injection therapy Medical care Naturopathic medicine Nutritional supplement Occupational therapy Osteopathic medicine Over-the-counter medications Physical therapy Prescribed medications Psychotherapy Reiki Surgery OTHERWere any diagnostic tests performed to assess this condition (including X-rays, MRIs, etc.)? YES NO UnsureHave you ever had any previous episodes of this condition? YES NOIn what ways does this condition affect your life and your ability to function? Choose all that apply. Bending over Caring for family Climbing stairs Concentrating Dressing myself Driving a car Exercising Getting in/out of car Getting to sleep Grocery shopping Household chores Lifting objects Looking over shoulder Love life Reiki Surgery OTHERPast, Family and Social HistoryYour Medical History Abdominal aortic aneurysm repair Appendectomy Biopsy Bunionectomy Cardiac bypass Cardiac valve replacement Carpal tunnel - left Carpal tunnel - right Cataract - left Cataract - right C-section Cosmetic - face lift Cosmetic - nose Cosmetic - breast reduction or enlargement Cosmetic - tummy tuck Cosmetic - other Ear tubes Gall bladder removed Gastric bypass Hysterectomy - complete Hysterectomy - partial Knee - left Knee - right Lasik Mastectomy Shoulder - left Shoulder - right Thyroidectomy Tonsils Tonsils & adenoids Wisdom teeth Discectomy level Implants Ganglion cyst Spinal fusion Transplant OTHERYour Past Illnesses AIDS/HIV Alcoholism Alzheimer's Anemia Anorexia Arthritis Asthma Bleeding disorders Breast lump Bronchitis Bulimia Cancer Chemical dependency Congenital anomaly Depression Diabetes Emphysema Epilepsy Extremity issues Fracture Heart disease Hepatitis Hereditary disorder Hernia Herniated disc High blood pressure High cholesterol Hospitalization Kidney disease Liver disease Migraine headaches Miscarriage Multiple sclerosis Natural labor Neuromuscular issues Osteoarthritis Osteoporosis Pacemaker Parkinson's disease Pinched nerve Pneumonia Polio Previous chiropractic care Prostate problems Psychiatric care Rheumatoid arthritis Stroke Suicide attempt Thyroid problems Trauma/injury Tumor Ulcers Vaginal infection Venereal disease OTHERList any past history of accidents or trauma. Choose all that apply. No previous trauma reported No new trauma reported since initial intake Single automobile accident Multiple automobile accidents Slip and fall Multiple slip and falls Single motorcycle accident Multiple motorcycles accidents Single boating accident Multiple boating accidents Resulting in fracture(s) Resulting in permanent injury or disability Resulting in hospitalization(s) Resulting in no significant injury or loss Resulting in sprains/strains Resulting in loss of consciousness Suicide attempts OTHERAre you presently taking any medication? YES NOYour Past Illnesses No family history of diabetes, cancer, hypertension and progressive neurological disorders. Unknown AIDS/HIV Alcoholism Alzheimer's Anemia Anorexia Arthritis Asthma Bleeding disorders Breast lump Bronchitis Bulimia Cancer Chemical dependency Congenital anomaly Depression Diabetes Emphysema Epilepsy Extremity issues Fracture Heart disease Hepatitis Hereditary disorder Hernia Herniated disc High blood pressure High cholesterol Hospitalization Kidney disease Liver disease Migraine headaches Miscarriage Multiple sclerosis Natural labor Neuromuscular issues Osteoarthritis Trauma/injury OTHERWhat are your (or are the patient's) current work habits? Choose all that apply. None reported No change in work habits since condition began Cannot not work due to presenting condition Permanently fully disabled Permanently partially disabled Full-time Part-time Homemaker Retired Student Unemployed 0 to 20 hours per week 20 to 40 hours per week 40 to 50 hours per week 50 to 60 hours per week 60 to 70 hours per week Over 70 hours per week Mostly sitting Mostly standing Mostly walking Light labor Moderate labor Heavy labor Sedentary Computer Repetitive Telephone Difficult Enjoyable Relaxed StressfulHow would you describe your (or the patient's) personal social habits? Choose all that apply. No change in social habits since injury. Does not smoke, drink alcohol or take recreational drugs. A social drinker Current every day smoker Current some day smoker Ex-smoker Heavy tobacco smoker Light tobacco smoker Never smoked tobacco Smoker, current status unknown Unknown if ever smoked A light drinker A moderate drinker A heavy drinker An alcoholic A recovering alcoholic Does not drink caffeine Drinks 1 cup of caffeine in the morning Drinks 2 to 4 cups of caffeine per day Drinks 5 or more cups of caffeine per day Does not use recreational drugs Light use of recreational drugs Moderate use of recreational drugs Heavy use of recreational drugs Is drug addicted Is A recovering drug addictHow would you describe your (or the patient's) present exercise habits? Choose all that apply. No changes in exercise habits since condition began Daily None Every other day Few times a week Once a week Almost nothing Aerobic Stretching Strength Baseball Basketball Blading Boating Climbing Cycling Football Golf Handball Hang gliding Hiking Ice skating Mountain climbing Ping-Pong Racquetball Running Skiing Skydiving Snowboarding Soccer Surfing Tennis Volleyball Walking Waterskiing Weight training Weight training with a personal trainer Pilates Spinning Step Yoga Zumba OTHERHow would you describe your (or the patient's) diet and nutritional status? Choose all that apply. No changes in diet or nutrition since condition began Controlled Out-of-control Restricted Unrestricted 1 to 2 meals a day 2 to 3 meals a day More than 3 meals a day Reports eating too little Reports eating too much Binges Purges Balanced High protein Low carbohydrate Low-fat Low-cholesterol No red meat Atkins Diabetic Gluten free Ideal Protein Jenny Craig Kosher Macrobiotic Paleo Raw food South Beach Vegan Vegetarian Weight Watchers Zone Does not take daily supplements Takes daily supplements OTHERFor Men OnlyDo you have pain or lump in scrotum or testicles? YES NO NOT SUREDo you have impaired libido (sex drive)? YES NO NOT SUREDo you have discharge from your penis? YES NO NOT SUREDo you have prostate problems? YES NO NOT SUREEstimate the date of your most recent prostate exam: MM slash DD slash YYYY Estimate the date of your most recent PSA (Prostate-Specific Antigen) test: MM slash DD slash YYYY What was your PSA (Prostate-Specific Antigen) level on your latest test?LowModerateHighHaven't had oneDon't knowFor Women OnlyAre you pregnant? YES NO NOT SUREAre you nursing? YES NOAre you taking birth control? YES NODo you experience painful periods? YES NODo you have irregular cycles? YES NODo you have breast implants? YES NODo you perform a regular self breast examination? YES NODo you take hormone replacement therapy (HRT)? YES NODo you take oral contraceptives? YES NOEstimate the date of your most recent PAP/pelvic exam: MM slash DD slash YYYY Date of last mammogram? MM slash DD slash YYYY Date of Last Menstrual Period? MM slash DD slash YYYY AuthorizationI certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment. * I agree with this statement of authorizationName First Last Date MM slash DD slash YYYY
