New Patient Information and Health History Name* First Last Date Email* (Your email will NOT be shared with any 3d parties, and is used for occasional office announcements and promotions.)Mailing AddressAddress Street Address City ZIP / Postal Code Telephone (Home) Telephone (Work)Referred By Age Birth Date Social Security # Employer Emergency ContactPhoneCurrent ComplaintsNature of Injury Automobile* Work Other Reason for Visit: Date of Injury Date Symptons Appeared Have you ever had same condition? NoYesIf yes, when? List other practioners seen for this injury/condition Have you ever been under chiropractic care? NoYesIf yes, please describe Insurance InformationName of insurance, PPO or HMO Phone if out of state insurance, found on the back of the card Do you have health insurance? NoYesMember ID# SignaturesName of the Insured _____________________________________________ I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable. I, the undersigned certify that I (or my dependent) have insurance coverage with the above listed company and assign directly to Chiro-Health, Inc. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. Patient's signature _______________________________________________ Date ____________________ Spouse's or guardian's signature __________________________________ Date ____________________Medical HistoryHave you been treated for this condition in the last year? NoYesIf yes, please describe Date of last physical exam Is there a chance that you are pregnant?NoYesHave you had X-rays taken? NoYesIf Yes, where? What medications/vitamins, minerals or herbs do you currently take? Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain). Describe the type of pain: sharp, dull, throbbing, tingling, stiff, achy, other. Have you ever:Broken bones? NoYesBriefly explain Been hospitalized?NoYesBriefly explain Been in auto accident? NoYesBriefly explain Had Sprains/Strains? NoYesBriefly explain Been struck unconscious?NoYesBriefly explain Had surgery? NoYesBriefly explain Section BreakUntitled Do you experience pain every day? NoYesDo your symptoms interfere with daily life? NoYesDoes pain wake you up at night? NoYesAre your symptoms worse during certain times of the day? NoYesDo changes in weather affect your symptoms? NoYesDo you wear orthotics? NoYesDo you take vitamin supplements? NoYesWhat activities aggravate your symptoms? HabitsAlcohol NoneLightModerateHeavyCoffee NoneLightModerateHeavyTobacco NoneLightModerateHeavyDrugs NoneLightModerateHeavyExercise NoneLightModerateHeavySleep NoneLightModerateHeavyAppetite NoneLightModerateHeavySoft Drinks NoneLightModerateHeavyWater NoneLightModerateHeavySalty Foods NoneLightModerateHeavySugary FoodsNoneLightModerateHeavyArtificial Sweeteners NoneLightModerateHeavyHave you ever suffered from: Alcoholism Allergies Anemia Arteriosclerosis Arthritis Asthma Back Pain Breast Lump Bronchitis Bruise Easily Cancer Chest Pain Cold Extremities Constipation Cramps Depression Diabetes Digestion Problems Dizziness Ears Ring Excessive Menstruation Eye Pain or Difficulties Fatigue Frequent Urination Headache Hemorrhoids High Blood Pressure Hot Flashes Irregular Heart Beat Irregular Cycle Kidney Infection Kidney Stones Loss of memory Loss of balance Loss of smell Loss of taste Lumps In Breast Neck Pain or Stiffness Nervousness Nosebleeds Pacemaker Polio Poor Posture Prostate Trouble Sciatica Shortness of breath Sinus Infection Sleep problems or Insomnia Spinal Curvatures Stroke Swelling of ankles Swollen Joints Thyroid Condition Tuberculosis Ulcers Varicose Veins Venereal Disease Other OtherIn order to provide you the best possible wellness care, please complete this formCommentsThis field is for validation purposes and should be left unchanged.