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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