Patient Intake Form

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Patient Intake Form

Personal Information
Name:		Birth date:
Email:		Contact Number:
Gender	Male Female	Marital Status:	Single Married
Address:			Divorced Widowed
City:
State:		Significant Other's Name:
Zip Code:		Significant Other's Work Phone:

Appointment Information
Desired Appt. Day:		Referred By:
Desired Appt. Time:		Medical Physician's Name:

Employer Information
Employer:		Employer's Address:
Occupation:		Employer's City:
Work Phone:		Employer's State:
		Employer's Zip Code:

Insurance Information
Ins. Co. Name:		Ins. Co. ID#:
Ins. Co. Address:		Ins. Co. Phone:
Ins. Co. City:		Insured's Name:
Ins. Co. State:		Relationship:
Ins. Co. Zip Code:		Insured's Employer:

Reason for Visit
Have you had previous chiropractic care?:		How did condition develop?:
What is your major complaint?:		Date of onset:
Other Complaints:		Does anything offer relief?:
On a scale from 0 to 10, 10 being the worst pain you can imagine and 0 being no pain, where would you rate your pain?
Have you had the same or similar problens in the past?:		Yes No
Is this condition getting worse?:		Yes No Constant Comes & goes
How would you describe the discomfort?:		Sharp Dull Achey Throbbing
What percent of the time does this condition bother you?:		0% 25% 50% 80%

Health History
Are you taking any of the following medications?
Nerve pills	Pain killers (incl. aspirin)	Muscle relaxers
Stimulants	Blood thinners	Tranquilizers
		Insulin
Other medications:

Check all health conditions that apply:
Heart Attack/Stroke	Shingles	Artifical Bones/Joints
Heart Surgery/Pacemaker	Cancer	Ulcer/Colitis
Heart Murmur	Frequent Neck Pain	Fainting/Seizures/Epilepsy
Congenital Heart Defect	Emphysema/Glaucoma	Sinus Problems
Mitral Valve Prolapse	Anemia	Diabetes/Tuberculosis
Artificial Valves	Lower Back Pain	Difficulty Breathing
Alcohol/Drug Abuse	Psychiatric Problems	High/Low Blood Pressure
Venereal Disease	Rheumatic Fever	Severe/Frequent Headaches
Hepatitis	Arthritis	Asthma
HIV+/AIDS	Kidney Problems	Chemotherapy


Please list any other serious medical condition(s) you have or ever had:		Describe what exercise you do:
Please list anything that you may be allergic to:		Do you smoke?:	Yes No
Please list anything that you may be allergic to:		If you smoke, how much?
List all previous surgeries/ treatments with dates:		Do you wear?:	Heel lifts Sole lifts Inner soles Arch support
List any and all accidents with dates:		What is the age of your mattress?:
Do you exercise regularly?	Yes No	Is your mattress comfortable?	Yes No
For Women
Are you taking birth control?:	Yes No	Are you pregnant?	Yes No
Are you nursing?:	Yes No	If so, how long have you been pregnant?: