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 ---SingleMarriedPartneredDivorcedWidowedMinor Sex ---MaleFemaleOther 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) 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? 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?