New Patient

Ashton Chiropractic Center
5939 SE Belmont St, Ste A, Portland, OR 97215 (map it)
PHONE | 503.231.8877
FAX | 503.231.8887

Hours: Monday-Friday 9am-6pm • Saturday 8am-2pm


PATIENT INFORMATION
Your Name*
Email*
Address
City
State & Zip
Home Phone
Cell Phone
Work Number
Marital Status
Sex
Birthday
Occupation
Patient Employer/School
Who do we thank for referring you?
Who is responsible for this account?* SelfInsurance CompanyGuardian Name
Insurance Company
Insurance ID#

IN CASE OF EMERGENCY, CONTACT

Name*
Email:
Home Phone:
Primary Care Physician
Phone

ACCIDENT INFORMATION

Is this condition due to an accident?
Date of accident
To whom have
you made report of your accident?
Auto InsuranceEmployerWorker CompOther
Claim #
Attorney Name

PATIENT CONDITION

Reason for your visit
When did your symptoms appear?
Is this condition getting progressively worse?
Please describe where you have pain, numbness, or tingling.
Rate the severity of pain from 0(no pain) to 10 (most pain you can imagine)
Type of pain: SharpDullThrobbingNumbnessAchingShootingBurningTinglingCrampsStiffnessSwellingOther
Location of numbness or tingling
How often do you have these symptoms?
Is it constant or does it come and go?
Does it interfere with your: WorkSleepDaily RoutineRecreation
Activities that are painful: SittingStandingWalkingBendingLying DownLovemaking
Are you experiencing any other symptoms in your body?

HEALTH HISTORY

What treatment have you already had for your condition? MedicationsSurgeryPhysical TherapyChiropractic ServicesNoneOther
Name of other practitioners who have treated you for this condition:
Have you ever had chiropractic care?
>Date of last Physical Exam.
Date of last X-Ray
In what area did you have your last X-Ray?
Date of last Spinal Exam
Date of last MRI, CT-Scan or Bone Scan
In what area did you have your last MRI, CT-Scan or Bone Scan?
Place a mark in the box to indicate if you have had any of the following: Arm/Hand PainArthritisBleeding DisordersBreathing ProblemsCancerCataractsChicken PoxChemical Dependency DiabetesDigestion ProblemsDizzinessEmphysemaEpilepsyFaintingFibroidsGlaucomaGonorrheaHeadachesHearing DifficultyHerniaHeart DiseaseHerniated DiscHepatitisHigh Blood PressureHigh CholesterolHIV/AIDSJaw ProblemsKidney DiseaseLeg/Foot ProblemsLiver DiseaseLow Back ProblemsMultiple SclerosisNeck Pain/StiffnessOsteoporosisPacemakerParkinson's DiseasePinched NervePneumoniaPolioProsthesisPsychiatric CareRheumatoid ArthritisRheumatic FeverScoliosisShoulder ProblemsStrokeThyroid ProblemsTIATuberculosisTumors/GrowthsVenereal DiseaseOther Conditions Not Listed
Exercise NoneModerateDailyHeavy
Describe Exercise Routine
Work Activity SittingStandingLight LaborHeavy Labor
Do you Smoke?
How many cigarettes/packs per day?
How long have you been smoking?

Do you drink alcohol?
Number of alcoholic drinks per day/week
Number of caffeine cups/day.
Do you have a high stress level?
Reason for stress level.

INJURIES/SURGERIES

Include a date and a description

Falls:
Head Injuries:
Broken Bones:
Dislocations:
Surgeries:
Car Accidents:

FAMILY HEALTH HISTORY

Has anyone in your immediate family had the following conditions? (Including your grandparents): Heart DiseaseStrokeCancerDiabetes
Describe selected conditions:
Any other diseases run in your family?

MEDICATIONS

Medications you are taking: For what condition(s)? Dosage(s): Vitamins/Herbs/Supplements: Dosage(s): List all Allergies: Is there anything else you would like to share with your doctor?

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