Chiropractic New Patient Intake Form

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New Patient Intake Form
First Name ___________________ Middle Initial ____ Last Name __________________________
Address _____________________________________________________________________
City _______________________________ State ___________________ Zip Code ______________
Home Phone (_____) ________-______
Cell Phone (_____) ________-___________
_____
Email _____________________________________________________
 Male
 Female
Date of Birth
Sex:
______/______/_______
Marital Status:  Single  Married  Other
Children:
Yes
No
Ages:_______________
Employment Status:  Employed  Unemployed  FT Student  PT Student  Other_____
Emergency Contact_________________________________________________________________
Contact Name ____________________________ Relationship to Patient ___________________
Contact Phone (_____) _______-________
Would you like us to verify your health insurance coverage?
Yes
No
How did you hear about our office? ___________________________________________________
Do you have a primary complaint?____________________________________________________
When and how did it begin? __________________________________________________________
What makes it better?_________________________________Worse? ________________________
(*Women Only) Are you pregnant? Yes_____ No ______Uncertain______
Please mark on the diagram where your pain is
occurring.
If you are currently experiencing pain, is it: (Mark
all that apply)
Sharp _____ Dull Ache _____ Burning _____
Throbbing _____ Stabbing _____ Shooting _____
Numbness _____ Tingling _______
Does the pain:
Come and go
Constant
How often does the pain occur? Hourly___
Daily___ Weekly___ Occasionally___ N/A___
If the pain travels, where does it
go?_________________________________________
How would you rate your pain? (0 = no pain, 10 =
worst pain possible): 0 1 2 3 4 5 6 7 8 9 10
Since the onset, has the complaint? Improved___
Worsened___ Stayed the same___ N/A___
Is this keeping you from...
Working___ Exercising___ Sports/hobbies___ Driving___ Sleeping___ Family Time___
How would you rate your HEALTH right now? (0 = Unhealthy, 10 = Optimum Health)
0 1 2 3 4
5
6 7 8
9 10
Have you ever been under chiropractic care? If so, when?
_______________________________________________________________________________
Following, is a list of diseases/conditions which may seem unrelated to the purpose of your appointment.
However, these questions must be answered carefully as these problems can affect your overall course of
care. Mark the following conditions that are CURRENTLY a cause of significant concern.
1

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