New Patient New Patient Information Patient InformationPlease complete the form and accept the cancellation policy.Last Name*First Name*M.I.Date* Street Address*Apt/Unit #City*State*Zip*Email Cell Phone*Work PhoneS.S. #*Date of birth* Age*Sex* Male Female Marital Status Single Married Divorced Widowed If a minor, legal guardianEmergency ContactName* First Last Address Same as previous Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Relationship*Home PhoneCell Phone*Medical Insurance InformationInsurance Carrier*ID Card #Policy Holder*Policy Holder Date of Birth* Policy Holder EmployerPolicy Holder SSNHealth ConditionPrimary Care PhysicianPhoneHow did you hear about us?*Condition for which being seen*Began:*Has it occurred before?* Yes No How did it happen?*Auto relatedJob relatedHave you seen another doctor for this?*YesNoIf yes, who?Type of treatmentWere you satisfied with this treatmentYesNoIf no, explain:Do you suffer with any other condition that which you are now consulting us?Are you wearing Heel lifts Sole lifts Inner soles Arch supports Current Medications (list medications)Past Health HistoryHave you seen a chiropractor before?*YesNoName of doctor?Date of last visit Please list all childhood health conditions:*Please list all adult health conditions:*Please list all surgeries:*Females Only (I Am)PregnantNot pregnantUnsurePrevious Injuries and Date of OccurenceIf you've had one of these injuries please indicate by adding a date (mm/yyyy). Otherwise leave blank.Back InjuryHead InjuryBroken BonesIndustrial AccidentDisabilityJoint InjuryFall (severe)Laceration (severe)FractureMotor Vehicle AccidentSoft Tissue InjuryOther:Social HistoryDo you smoke/chew?*YesNoDo you drink?*YesNoHow many times per week do you smoke/chew?*How many times per week do you drink?*Family Health HistoryCheck all that apply to your familyCondition Arthritis Back Trouble Cancer Diabetes Emphysema Headaches High Blood Pressure Kidney Trouble Migraines Pinched Nerve Sinus Trouble Asthma-Hay Fever Bursitis Constipation Disc Problem Epilepsy Heart Trouble Insomnia Liver Trouble Neuralgia Scoliosis Stomach Trouble Relative(s) w/ ArthritisRelative(s) w/ back troubleRelative(s) w/ CancerRelative(s) w/ DiabetesRelative(s) w/ EmphysemaRelative(s) w/ headachesRelative(s) w/ high blood pressureRelative(s) w/ kidney troubleRelative(s) w/ migrainesRelative(s) w/ pinched nerveRelative(s) w/ sinus troubleRelative(s) w/ asthma-hay feverRelative(s) w/ BursitisRelative(s) w/ ConstipationRelative(s) w/ disc problemRelative(s) w/ EpilepsyRelative(s) w/ heart troubleRelative(s) w/ InsomniaRelative(s) w/ liver troubleRelative(s) w/ NeuralgiaRelative(s) w/ ScoliosisRelative(s) w/ stomach troubleI understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that the Chiropractic Clinic will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to the Chiropractic Clinic will be credited to my account upon receipt. However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care of treatment, any fees for professional services rendered me will be immediately due and payable. I hereby authorize the Doctor to treat my condition as he or she deems appropriate through the use of Chiropractic Health Care, and I give authority for these procedures to be performed. It is understood and agreed the amount paid to the Doctor, for x-rays, is for examination only and the x-ray negative will remain the property of this office, being on file where they may be seen at any time while a patient of this office. The patient also agrees that he/she is responsible for all bills incurred at this office.By checking this box I certify that I have read and I agree with the above statements. I Agree Signature*PhoneThis field is for validation purposes and should be left unchanged.