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
    Sex (if other):
    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?