New Patient

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

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)

012345678910

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?

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.

Falls:

Head Injuries:

Broken Bones:

Dislocations:

Surgeries:

Car Accidents:

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 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?