Patient Intake Form

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In order to provide you the best possible wellness care, please complete this form.

Patient Data
Name *	Date

Email * (Your email will NOT be shared with any 3d parties, and is used for occasional office announcements and promotions.)



Mailing Address
Address	City
State	Zip
Telephone (Home)	Telephone (Work)
Referred By	Age
Birth Date	Social Security #
Number of Children	Occupation
Employer	Marital Status
Spouse's Name	Spouse's Occupation
Spouse's Employer	Spouse's Health Status
Emergency Contact	Phone



Current Complaints
Nature of Injury Auto Work Other	Please Describe

Date of Injury	Have you ever had same condition? No Yes
If yes, when?	List other practicioners seen for this injury/condition
Have you ever been under chiropractic care? No Yes

Insurance Information
Name of party responsible for payment	Phone
Do you have health insurance? No Yes	Name of company

Medical History
Have you been treated for any conditions in the last year? No Yes	If yes, please describe
Date of last physical exam	Is there a chance that you are pregnant? No Yes
Have you had X-rays taken? No Yes	What medications are you taking and for what conditions (Please list dosage and amounts, etc).
What vitamins, minerals, or herbs do you currently take? (Please list for what condition, dosage, and frequency).



Have you ever:
Broken bones? No Yes	Briefly explain
Been hospitalized? No Yes	Briefly explain
Been in auto accident? No Yes
Had Sprains/Strains? No Yes	Briefly explain
Been struck unconscious? No Yes	Briefly explain
Had surgery? No Yes	Briefly explain



Family History
Family members - Present and past health conditions (Example: heart disease, cancer, diabetes, arthritis, etc.)

Do you experience pain every day? No Yes	Do your symptoms interfere with daily life? No Yes
Does pain wake you up at night? No Yes	Are your symptoms worse during certain times of the day? No Yes
Do changes in weather affect your symptoms? No Yes	Do you wear orthotics? No Yes
Do you take vitamin supplements? No Yes	What activities aggravate your symptoms?



Habits
Alcohol None Light Moderate Heavy

Coffee None Light Moderate Heavy

Tobacco None Light Moderate Heavy

Drugs None Light Moderate Heavy

Exercise None Light Moderate Heavy

Sleep None Light Moderate Heavy

Appetite None Light Moderate Heavy

Soft Drinks None Light Moderate Heavy

Water None Light Moderate Heavy

Salty Foods None Light Moderate Heavy

Sugary Foods None Light Moderate Heavy

Artificial Sweeteners None Light Moderate Heavy



Have you ever suffered from:
Alcoholism	Irregular Cycle
Allergies	Kidney Infection
Anemia	Kidney Stones
Arteriosclerosis	Loss of memory
Arthritis	Loss of balance
Asthma	Loss of smell
Back Pain	Loss of taste
Breast lump	Lumps In Breast
Bronchitis	Neck Pain or Stiffness
Bruise Easily	Nervousness
Cancer	Nosebleeds
Chest Pain/Conditions	Pacemaker
Cold extremities	Polio
Constipation	Poor Posture
Cramps	Prostate Trouble
Depression	Sciatica
Diabetes	Shortness of breath
Digestion Problems	Sinus Infection
Dizziness	Sleep problems/insomnia
Ears Ring	Spinal Curvatures
Excessive Menstruation	Stroke
Eye Pain/Difficulties	Swelling of ankles
Fatigue	Swollen Joints
Frequent Urination	Thyroid Condition
Headache	Tuberculosis
Hemorrhoids	Ulcers
High Blood Pressure	Varicose Veins
Hot Flashes	Venereal Disease
Irregular Heart Beat	Other:

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