Chiropractic New Patient Form printable pdf download

W e l c o m e t o C h i r o p r a c t i c

P l e a s e P r i n t C l e a r l y a n d f i l l I n c o m p l e t e l y .

Name_______________________________________Email______________________________________

Street

Address____________________________________________Phone_____________________________

City___________________________State________Zip_____________

Date of

Birth_______________________

Please Check

Sex: Male Female

Right handed Left handed

Married Single

Health History:

Give reason for seeking chiropractic care:_________________________________________________________

___________________________________________________________________________________________

Describe any health problems, including how long you've had them:_____________________________________

___________________________________________________________________________________________

Are you under the care of any other doctor? Yes No

If Yes, the conditions being treated for:

___________________________________________________________________________________________

List any current Medications:____________________________________________________________________

List any past surgeries & dates:_________________________________________________________________

List any past accidents & dates:_________________________________________________________________

List any x-rays you've had in the past 2 years:______________________________________________________

Personal & Family History:

Your Occupation:_________________________ Work Duties_________________________________________

Spouse’s health status________________________________________________________________________

Children's ages and health status:_______________________________________________________________

Chiropractic History:

Have you ever been to a Chiropractor before? Yes No If yes Doctor's Name_________________________

Date of last chiropractic visit___________________Reason for care____________________________________

Date of last chiropractic x-rays_________________How long were you under care?________________________

Are other family members under chiropractic care? - Yes NoWho?________________________________

Wellness Commitment

At this Chiropractic office we are dedicated toward achieving the goal of total lasting health for our members. To

better help you achieve this, we need to understand your commitment toward being healthy. We do not ask for a

financial commitment, but we do ask for your cooperative commitment.

Based on a scale of 10% to 100%,

please circle your personal level of commitment toward obtaining and maintaining health and wellness.

10%--------20%--------30%--------40%--------50%--------60%--------70%--------80%--------90%--------100%

_____________________________________________________________________________________________________________________________

Where did you hear about our clinic,

or who referred you?__________________________________________________________________________

_______________________________________________________________________________________________________________________________________________________________________

Yes

No

Please Check One

FEMALES:

 Is there a possibility of you being pregnant?

Chiropractic New Patient Form

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