New Patient Forms Page 2
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3Have you seen any other doctors for this condition?
_____Chiropractor _____Medical Doctor _____Other
If so, WHO & WHEN _______________________________________________________________________
List Surgeries and Date__________________________________________________________________________
__________________________________________________________________________________________________
List all MEDICATIONS you are currently taking__________________________________________________
__________________________________________________________________________________________________
When was your last Auto Accident? ___________________________________________________________
Have you had previous chiropractic care? ____YES ____NO If YES, WHEN &
WHO__________________
Have you ever been knocked unconscious? ____YES ____NO
Fractured any bones? ____YES ____NO If YES, Please describe ______________________________
Any other bodily trauma? ______________________________________________________________________
CIRCLE ANY & ALL OF THESE PROBLEMS YOU’VE HAD IN THE LAST 2 YEARS
CHRONIC FATIGUE
DIZZINESS
ASTHMA
KIDNEY PROBLEMS
LUPUS
ULCERS
HEADACHES
BLADDER PROBLEMS
FYBROMYALGIA
VERTIGO
CHEST PAINS
IRRITABLE BLADDER
ADD / ADHD
ARM NUMBNESS
EAR INFECTIONS
SCIATICA
GERD
GRATING OF NECK
ARM PAIN
LEG NUMBNESS
NERVOUSNESS
TMJ
HAND NUMBNESS
FEET NUMBNESS
SHOULDER PAIN
EPILEPSY
NECK PAIN
LOW BACK PAIN
DISC PROBLEMS
MIGRAINES
HEART DISORDERS
HIP PAIN
INFERTILITY
MID BACK PAIN
STIFFNESS IN NECK
LEG PAINS
STOMACH DISORDERS
CHRONIC SINUS
KNEE PAIN
________
THROAT ISSUES
NAUSEA
LIVER DISEASE
OTHER
______________
REFLUX
THYROID ISSUES
MENSTRUAL ISSUES
ANXIETY
ADDICTION
DEPRESSION
CHECK ANY CONDITIONS YOU HAVE CURRENTLY OR IN THE PAST:
STROKE - CANCER - HEART DISEASE - SPINAL SURGERY - SEIZURES - SPINAL FRACTURE - SCOLIOSIS – DIABETES
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Parent category: Medical