New Patient Intake Form -

First Name

Last Name

Street

City

State

Zip

Cell Phone

SSN

Date of Birth

Age

Is it okay to text/email you?

Yes No

Cell Phone Carrier

Sex

Marital Status

# of children

Employer

Work Phone

Occupation

Name of spouse (or parent)

How did you hear about our office?

What is the name of your family physician?

Physicians Phone #

Have you ever had Chiropractic care before?

If yes, doctor's name

Date of last visit

How many visits this year?

If you are experiencing any pain (neck pain, mid back pain, low back pain, etc.), health problems, symptoms, and/or complaints, please list in order of severity

For how long?

Has this problem been getting worse or staying the same?

Yes No

If yes, please describe what activities at work may be causing you to experience these complaints Are there any other activities, incidents, or events outside of work that may have caused these complaints? If yes, please explain

Have you at any time in the past ever suffered a work injury?

Yes No

If yes, what is the date of injury?

Do you have an attorney representing you for this work injury?

Yes No

If yes, who is your attorney?

Have you been involved in an auto accident in the last 12 months?

Yes No

If yes, date of auto accident?

Do you have an attorney representing you for this auto accident?

Yes No

If yes, who is your attorney?

Have you ever had any surgeries or hospitalizations?

Yes No

If yes, please list

Please list any current or past injuries and illnesses not listed above Please check all medications (over the counter and/or prescribed) you are currently taking
Select all that apply

Health Insurance Co. Name

Policyholder

Name of Spouse's health insurance (If applicable)

Policyholder

Spouse's SSN (if applicable)

Spouse's Birthdate (if applicable)

The rating scale below is designed to measure the degree to which several aspects of your life are presently disrupted by your health condition (pain and/or symptoms you may be experiencing). In other words, we would like to know how much your health condition (pain and/or symptoms you may be experiencing) is preventing you from doing what you would normally do, or from doing it as well as you normally would. Respond to each category by indicating the overall impact of pain in your life, not just when then pain is at its worst.

For each of the six categories of daily living listed, PLEASE INDICATE THE NUMBER WHICH BEST DESCRIBES YOUR TYPICAL LEVEL OF ACTIVITIES. 0 means no disability at all, and a score of 10 means that all of the activities in which you would normally be involved have been totally disrupted or prevented by your health condition (pain and/or symptoms you may be experiencing).

1. FAMILY/HOME RESPONSIBILITIES: activities related to the home or family including chores and duties performed around the house (yard work, doing dishes, errands, favors for other family members, driving children to school, etc.)

2. RECREATION: hobbies, sports, and other similar leisure time activities.

3. SOCIAL ACTIVITY: activities which involve participation with friends and acquaintances other than family members including parties, theater, concerts, dining out, and other social functions.

4. OCCUPATON: activities that are a part of or directly related to one’s job including nonpaying jobs as well, such as that of a homemaker or volunteer worker.

5. SELF CARE: activities which involve personal maintenance and independent daily living (taking a shower, driving, getting dressed, etc.)

6. LIFE SUPPORT ACTIVITY: basic life supporting behaviors such as eating, sleeping and breathing.