New Patient Intake Form

(Internal use) Date: ______________ (Internal use) File # ______________

Personal Profile

Full Name *

Address *

City *

Postal code *

Phone *

Email *

Date of birth *

Age *

Gender *

Marital Status *

Occupation *

Family Information

Spouse's Name (If applicable)

Spouse's Occupation (If applicable)

Do you have children? *

If yes, what are their names and ages?

If you are under 18, what are your parent's names?

Females Only

Are you pregnant?

If yes, how many weeks?

If yes, is this your first pregnancy?

Insurance and previous care

Do you have extended health insurance? *

If yes, with which insurance company?

$ Participation/Year

Insurance Renewal Date

How were you referred to our office? *

Have you ever received chiropractic care before? *

Is yes, please provide details of when, the doctor's name and # years under care.

Reason For Visit

Is this visit for a general wellness checkup? *

Health Motivations

If you don't get this problem/s corrected, do you think it will get worse in the next... *

1 year

2 years

5 years

Besides taking care of the above concerns, what is your greatest motivation for wanting to get better, be healthier? *

On a scale of 1 to 10 (10 being the highest), rate your commitment to improving your health: *

Traumas & Stresses

What are the FIVE most serious physical traumas/stresses that you've experienced (eg. Automobile jarring/impacts, work stresses, recreational activities, sports, falls, fractures...etc.)

Trauma 1 - Please describe the event and date of occurrence *

Trauma 2 - Please describe the event and date of occurrence *

Trauma 3 - Please describe the event and date of occurrence *

Trauma 4 - Please describe the event and date of occurrence *

How would you rate your mental/emotional stress levels? (Rate 1 to 10, 10 being high): *

If you indicated emotional stress, what is causing this?

Work

Family

Home

Other

If other, please explain:

Does your family have a history of Cancer, Diabetes, Hypertension or illness? *

Have you ever been hospitalized? If so, please describe: *

Have you had any surgeries? *

Please list any medications that you are presently or have taken in the last 5 years: *

Have you had x-rays previously taken? If so, when? *