Your Information
Have You Visited Pompano Beach Chiropractic Center Before?
I'm a New Patient
Yes, I Have
First Name
Last Name
Address
Street Address
City
State
Country
Country
Postal code
Phone
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Email
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Date of birth
Occupation
Employer
Marital Status
How Did You Hear About Us?
Emergency Contact
Emergency Contact Full Name
Relationship
Emergency Phone
Your Insurance
Primary Insurance Company
Subscriber Name
Plan
Reason for Appointment
If Injured, What Body Part?
Side of Body
Injury Date
Please Briefly Describe Injury
Were You Seen In the Emergency Room
Yes, I was
No, I was not
If yes, where were you seen?
Past Medical History
Have you ever had:
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Are You Currently On Any Medications?
Yes, I am
No, I am not
If you answered yes, please lest all medications (Name, Dosage, Frequency) OR Upload Image of Labels Below
Take a Picture of Medication Label
Prescription Label Upload
Take a Picture of Medication Label
PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF
Do You Have Allergies?
Yes, I do
No, I do not
If yes, please include all allergens (Medications, Foods, Seasonal)
Surgical History:
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Family History:
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Do you have either/both of the following:
Do you smoke?
Yes, I do
No, I do not
If you smoke, how many cigarettes per day and how many years have you been smoking?
Do you consume alcohol?
Yes, I do
No, I do not
If you drink, how many drinks per day/week?
Body Systems Review
Constitutional Symptoms
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Eyes/Vision
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Ears Nose Mouth & Throat
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Cardiovascular System
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Gastrointestinal System
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Psychiatric Health
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Neurological System
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Genitourinary System
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Intergumentary System & Breast Health
Endocrine System
Endocrine System
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Hematologic & Lymphatic System
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