New Patients Form 2018-01-04T05:34:32+00:00

New Patient Form:

Welcome to our online New Patient Form. The information you fill in will be sent directly to our office, speed up your office visit, and will help us to better serve your healthcare needs. Please take a moment to completely fill out this form, and upon completion of all form categories click the [Submit] button at the bottom.

Please answer the following questions as best you can.
* Required Fields

Personal Information




* Sex MaleFemale

* Language(s) Spoken

* Race:
WhiteAmerican Indian or Alaskan NativeAsianNative Hawaiian/Other Pacific IslanderBlack or African AmericanHispanic or LatinoDecline to AnswerOther

* Ethnicity:
Hispanic or LatinoNot Hispanic or LatinoDecline to Answer



Contact Info










Insurance & Payment for Care


* Method of Payment?
Health InsMedicarePersonal InjuryCashOther

Insurance Information













Current Symptoms


Have You Received Any Treatment For These Complaints?: YesNo

Medical Diagnosis: YesNo

Headaches: YesNo

If yes, which part of your head hurts?
FrontBackSidesTop

Neck Pain: YesNo

If yes, how would you describe the pain?
Sharp/RadiatingDull/AcheSore/Tender

Back Pain: YesNo

If yes, how would you describe the pain?
Sharp/RadiatingDull/AcheSore/Tender

Shoulders Pain: YesNo

If yes, which shoulder? RightLeftBoth

Hips Pain: YesNo

If yes, which side of the hip? RightLeftBoth

Legs/Feet: YesNo

If yes, which leg/foot? RightLeftBoth

Arms/Hands: YesNo

If yes, which arm/hand? RightLeftBoth

Numbness/Tingling: YesNo

Dizziness/Fainting: YesNo

Memory Problems: YesNo

Difficulty Sleeping: YesNo

Personal Health History





Have You Ever Been To A Chiropractor Before? YesNo

Pregnant? YesNo

Have You Ever Tested Positive For HIV/Aids?: YesNo
Do You Use Sleeping Pills? YesNo
Do You Take Insulin? YesNo
Do You Wear Contact Lenses? YesNo
Do You Have Epilepsy?: YesNo
Are Your Parents Still Living? YesNo

Personal Incident History


Heart Problems? YesNo

Lung Problems? YesNo

Liver Problems? YesNo

Gall Bladder Problems? YesNo

Intestinal Problems? YesNo

Kidney Problems? YesNo

Thyroid Problems? YesNo

Tonsil Problems? YesNo

Anemia Problems? YesNo

Mouth/Teeth Problems? YesNo

Eye Problems? YesNo

Nose/Sinuse Problems? YesNo

Digestive Problems? YesNo

If yes, please check all that apply:
GasNauseaVomittingAppetite ProblemsOther

Have you ever had a growth removed such as a Mole, Wart, or Cancer?
YesNo

Have you ever been paralyzed at any part of your body?
YesNo

Any Operations? YesNo

What Drugs And/Or Medications Are You Taking?

Any Accidents, Bad Falls, Sprains, or Wounds Received and When?

Authorization


I have read the above information and certify it to be true and correct to the best of my knowledge, and hereby authorize this office of Chiropractic to do whatever is necessary in accordance with this state's statues, to provide me with chiropractic care.

Patient or Guardian Signature:

OFFICE ADDRESS

OFFICE HOURS

Monday – Thursday9 AM – 1 PM
Monday – Thursday3 PM – 6 PM
Friday9 AM – 12 PM

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