New Patient Form
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3TODAY’S DATE: ____/____/________
FILE #:_____________________________
WELCOME
PERSONAL INFORMATION
Patient Name:_________________________________________________Preferred Name: _______________________________________________________
Birthdate: ________/________/____ ____Age: _____________❑ Male
SSN:__________________________________________________
❑ Female
Mailing Address:_____________________________________________City: _________________________________State: ____________Zip: ______________
Daytime Phone: _____________________________Evening Phone: _____________________________Email: _______________________________________
Status: ❑ Minor ❑ Married ❑ Divorced ❑ Seperated ❑ Widowed
Children: ❑ Yes ❑ No
How Many:_______
Spouses Name:________________________________________________Referred By: ____________________________________________________________
EMPLOYMENT INFORMATION
Employer: _____________________________________________________Occupation: ________________________________How long?:________________
Address: ______________________________________________________City: _______________________________State: ____________Zip: ______________
INSURANCE INFORMATION
Company Name:______________________________________________Phone #: _______________________________________________________________
Address: ______________________________________________________City: _______________________________State: ____________Zip: ______________
Insured’s Id#: __________________________________________________Group # (Plan, Local, Policy #): __________________________________________
Insured’s Name: _______________________________________________Relation: _______________________________________________________________
Date Of Birth: ____/____/________
Insured’s Employer: _____________________________________________________
Please inform front desk of second insurance source.
REASON FOR VISIT
The reason for this visit is a result of: ❑ Work ❑ Sports ❑ Auto ❑ Trauma ❑ Chronic
Explain what happened:_______________________________________________________________________________________________________________
Please describe the pain & its location:: ________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
When did condition begin? ____/____/________ Is it getting worse?
❑ Comes And Goes
❑ Yes
❑ No
❑ Constant
Does it interfere with your ❑ Work ❑ Sleep ❑ Daily Routine
Explain: ________________________________________________________________
Have you had this or similar conditions in the past? ❑ Yes ❑ No Explain: ________________________________________________________________
Have you been treated by a medical physician for this condition: ❑ Yes ❑ No
If so, where? __________________________________________________________________________________________________________________________
Have you even been treated by a chiropractor before? ❑ Yes ❑ No
If so, whom? _________________________________________
Phone #: ____________________________________
Are you familiar with the Health Healing System?: ❑ Yes ❑ No
What stage are you in? ❑ Relief ❑ Restoration ❑ Revitalization ❑ Praktikos
Have you had a O.N.C.E. Exam?
❑ Yes ❑ No
PICKERINGTON OFFICE • 614-861-1333
1700 CROSS CREEKS BLVD • PICKERINGTON, OH 43147
WESTERVILLE OFFICE • 614-890-2740
642 BROOKSEDGE BLVD • WESTERVILLE, OH 43081
NEW PATIENT FORM • PAGE 1
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Parent category: Medical