CHIROPRACTIC NEW PATIENT FORM

2. How long have you been experiencing your symptoms?

3. How often do you experience your symptoms?

4. On a scale of 1 (mild) to 10 (severe), how bad are your symptoms?

5. What makes your symptoms better?

worse?

6. Have you had these symptoms? If so, when?

7. Any other health changes in the 3 months?

8. Have you seen any doctor about your complaint?

Yes

No

Who Treatment

9. Are you currently seeing another doctor for other reasons?

Yes

No

10. Current Medication/ Supplements

Allergic to any Medication

11. Which of the following diseases affect your immediate family?

Other, relevant:

12. List Previous
a) Fractures/ Dislocation/ Injuries

b) Illnesses

c) Operations/ Hospitalizations

d) X- ray and When

13. Social History:

a) Do you smoke?

No

Yes

b) Do you exercise?

No

Yes

c) Daily Fluid:

Water

Coffee/ Tea

Alcohol/ Cold Drinks

I certify that it is my responsibility to pay all required fees for the procedures or treatments provided to me by the Dr. or Specialist.