New Patient History Form
Name
Date:
Address
SSN
City/State/Zip
Phone:
Home
Cell
Work_artist
Email
Address
Age
Date of birth
Sex:
M
F
Marital status:
S
M
D
W
Name of spouse/partner
Names and ages of children
Occupation
Employer
How did you hear about us?
What is your reason for seeking care with us?
Please rate yourself in the following categories—0 being poor and 5 excellent :
0
1
2
3
4
5
Overall physical health
0
1
2
3
4
5
Emotional/mental health
0
1
2
3
4
5
Overall quality of life
0
1
2
3
4
5
Ability to deal with and adapt to stress
How much stress is in your life—0 being very little and 5 very much?
0
1
2
3
4
5
Y
N
Have you ever been to a chiropractor or other nervous system specialist? If yes, list name(s) and method/technique used, if you know.
Do you have a primary care physician?
Name:
Do you consult him/her regularly? If so, for what reason?
Date of last medical consultation.
Have you ever been diagnosed or treated for any of the following conditions?
Aids/HIV
Allergies
Anxiety
Arthritis
Cancer
Depression
Diabetes
Heart disease
Scoliosis
Stroke
Teeth grinding
TMJ
Other
Please explain with dates.
Y
N
Has anyone in your immediate family ever suffered a serious mental or physical illness?
If so, please list relative and illness.
Emotional Stress : This may be from any time In your life that may still be affecting you
Each of life’s stresses is a potential cause of tension in the spine/nervous system. Rate the severity of each below— 0 being the least severe and 5 the most:
Abuse
0
1
2
3
4
5
Childhood
0
1
2
3
4
5
Commuting
0
1
2
3
4
5
Divorce/separation
0
1
2
3
4
5
Family
0
1
2
3
4
5
Financial
0
1
2
3
4
5
Friends
0
1
2
3
4
5
Illness
0
1
2
3
4
5
Illness of loved one
0
1
2
3
4
5
Work
0
1
2
3
4
5
Job loss
0
1
2
3
4
5
Loss of a loved one
0
1
2
3
4
5
Parents’ divorce
0
1
2
3
4
5
School
0
1
2
3
4
5
Lifestyle change
0
1
2
3
4
5
Other
0
1
2
3
4
5
Description and comments.
For women only:
Y
N
Are you pregnant?
Date of last monthly period.
Y
N
Are your periods painful? Please describe what your monthly cycle is like (pain-free, regular, painful with cramping, irreguar, etc).
Y
N
Have you ever been pregnant? If yes, note number and dates.
What were your pregnancies like? Please check all boxes below that apply to any of your births.
Breech
Caesarian
Forceps
Epidural
Y
N
Are you are in menopause or peri-menopause? If so, please describe what you are experiencing.
History of Physical Stress
Y
N
Have you ever sustained any head injuries?
Y
N
If so, were you knocked unconscious?
If yes, please explain with dates.
Y
N
Have you been in any of the following accidents?
Auto
Motorcycle
Bicycle
Describe with dates:
Y
N
Have you ever broken any bones? If yes, list with dates.
What other injuries have you had? Please list and describe with dates.
Y
N
DK Were there any difficulties associated with your mother’s pregnancy or your birth?
If yes, please describe.
Of the activities below, which you do regularly at work, home, or school?
Exercise
Lift
Reach
Stand
Sit
Use computer
Use phone
Have you had any of the following medical interventions?
Cast/collars
Chemotherapy
Hospitalization
Organ removal
Physiotherapy
Shoe lifts
Surgery
Spinal tap
Traction
X-ray therapy—extensive
Other
Explain with dates.
Y
N
Do you, or have you, served in the armed forces? If so, list dates.
History of Chemical Stress
Y
N
Have you been vaccinated?
Y
N
Are you currently taking any of the following?
Over-the-counter medication
Prescription medication
Vitamins
Herbs
Do you regularly consume any of the following?
Alcohol
Artificial sweetener
Caffeine
Meat
Recreational drugs
Refined sugar
Tap water
Tobacco
Other
Description/comments.
Do you currently, or have you ever, worked with any of the following?
Chemicals
Fumes sweetener
Smoke
Y
N
Is there anything else you would like to share which may help us to better understand you, and why you have chosen to come to this office?
Signature
Date: