New Patient Forms PATIENT INFORMATIONDate MM slash DD slash YYYY SS/HIC/Patient ID #Patient Name Last name Middle Initial First Name Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Email Sex Male Female AgeBirthdateMarital Status Married Separated Widowed Divorced Single Minor Partnered How many years?OccupationPatient Employer/SchoolEmployer/School AddressEmployer/School PhoneSpouse's NameBirthdateSS#Spouse's EmployerWhom may we thank for referring you?INSURANCEWho is responsible for this account?Relationship to Patient?Insurance Co.Group #Is patient covered by additional insurance? Yes No Subscriber's NameBirthdateSS#Relationship to PatientInsurance Co.Group #PHONE NUMBERSHome PhoneCell PhoneBest time and place to reach youIN CASE OF EMERGENCY, CONTACTNameRelationshipHome PhoneWork PhoneACCIDENT INFORMATIONIs this condition due to an accident? Yes No Date of accident MM slash DD slash YYYY Type of accident Auto Work Home Other To whom have you made a report of your accident? Auto Insurance Employer Worker's Compensation Other Attorney Name (if applicable)PATIENT CONDITIONReason for visitWhen did your symptoms appear?Is this condition getting progressively worse? Yes No Unknown Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain)SharpBurningDullTinglingThrobbingCrampsNumbnessStiffnessAchingSwellingShootingOtherHow often do you have this pain?Is it constant or does it come and go?Does it interfere with your Work Sleep Daily Routine Recreation Activities or movements that are painful to perform Sitting Standing Walking Bending Lying Down HEALTH HISTORYWhat treatment have you already received for your condition? Medications Surgery Physical Therapy Chiropractic Services None Other Please explainName and addres of other doctor(s) who have treated you for your conditionDate of last physical exam MM slash DD slash YYYY Spinal Exam MM slash DD slash YYYY Dental X-Ray MM slash DD slash YYYY Spinal X-Ray MM slash DD slash YYYY Chest X-Ray MM slash DD slash YYYY MRI, CT-Scan, Bone Scan MM slash DD slash YYYY Blood Test MM slash DD slash YYYY Urine Test MM slash DD slash YYYY AIDS/HIV Yes No Alcoholism Yes No Allergy Shots Yes No Anemia Yes No Anorexia Yes No Appendicitis Yes No Arthritis Yes No Asthma Yes No Bleeding Disorders Yes No Breast Lump Yes No Bronchitis Yes No Bulimia Yes No Cancer Yes No Cataracts Yes No Chemical Dependency Yes No Chicken Pox Yes No Diabetes Yes No Emphysema Yes No Epilepsy Yes No Fractures Yes No Glaucoma Yes No Goiter Yes No Gonorrhea Yes No Gout Yes No Heart Disease Yes No Hepatitis Yes No Hernia Yes No Herniated Disk Yes No Herpes Yes No High Blood Pressure Yes No High Cholesterol Yes No Kidney Disease Yes No Liver Disease Yes No Measles Yes No Migraine Headaches Yes No Miscarriage Yes No Mononucleosis Yes No Multiple Sclerosis Yes No Mumps Yes No Osteoporosis Yes No Pacemaker Yes No Parkinson's Disease Yes No Pinched Nerve Yes No Pneumonia Yes No Polio Yes No Prostate Problem Yes No Prosthesis Yes No Psychiatric Care Yes No Rheumatoid Arthritis Yes No Rheumatic Fever Yes No Scarlet Fever Yes No Sexually Transmitted Disease Yes No Stroke Yes No Suicide Attempt Yes No Thyroid Problems Yes No Tonsilitis Yes No Tuberculosis Yes No Tumors, Growths Yes No Typhoid Fever Yes No Ulcers Yes No Vaginal Infections Yes No Whooping Cough Yes No Exercise None Moderate Daily Heavy Work Activity Sitting Standing Light Labor Heavy Labor Habits Smoking Alcohol Coffee/Caffeine Drinks High Stress Level Packs/DayDrinks/WeekCups/DayReasonAre you pregnant? Yes No Due Date MM slash DD slash YYYY Injuries/Surgeries you have had Falls Head Injuries Broken Bones Dislocations Surgeries Description of FallDate MM slash DD slash YYYY Description of Head InjuryDate MM slash DD slash YYYY Description of Broken BonesDate MM slash DD slash YYYY Description of DislocationsDate MM slash DD slash YYYY Description of SurgeriesDate MM slash DD slash YYYY MedicationsPharmacy NamePharmacy PhoneAllergiesVitamins/Herbs/Minerals Δ
