New Patient Intake Form: Fill out this information below to the best of your knowledge and we will be in touch soon. Click submit at the bottom when finished. Please enable JavaScript in your browser to complete this form.Name: *Email *Address *City *State *Zip Code *Gender *MaleFemaleAge *Date of Birth *Marital Status *SingleMarriedWidowedSeparatedDivorcedOccupation *Employer *Employer Address *StudentStudent AttendanceFull-timePart-timeN/ASpouseSpouse Date of BirthSpouse OccupationSpouse EmployerReferralHome Number *Cell Number *Work NumberEmail *Best time to reach you *Emergency Contact Name *Emergency Contact Relationship *Emergency Contact Cell Number *Emergency Contact Other Number *Who is responsible for account *Relationship to Patient *Insurance Company *ID Number *CoveredYesNoSubscriber's Name *Subscriber's Date of Birth *Relationship to Subscriber *Subscriber's Insurance *Subscriber's ID *Insurance Company *Signature *Relationship to Subscriber *Date / TimeDateTimeAccidentYesNoDate of AccidentType of AccidentAutoHomeWorkOtherReported AccidentAuto InsuranceEmployerWorker CompOtherAttorney's NameAttorney's AddressAttorney's Phone NumberReason for Visit: *Symptoms? *What caused the symptoms? *Are they worse? *YesNoUnknownHave you had them previously? *YesNoIf yes, when:Please specify the area where the symptoms occur: *Severity of Pain (1 being none, 10 being unbearable) *12345678910Please check all symptoms that apply: *SharpDullThrobbingNumbnessAchingShootingBurningTinglingCrampsStiffnessSwellingOtherIf other, please describe. What time of day do the symptoms often occur? *Is the pain constant or does it come and go? *Does it interfere with your: (select all that apply) *WorkSleepDaily RoutineRecreationNumber of days lost from work or school: *Activities you'd like to be able to do again: *Activities or movements that are painful to perform (Select all that apply): *SittingStandingWalkingBendingLying DownLiftingStretchingOtherIf other, please describe: *Pain is reduced by (Select all that apply): *RestExerciseMedicineAdjustmentsTherapyWhat treatment have you already received for your condition? (Select all that apply): *MedicationsSurgeryPhysical TherapyChiropractic ServicesNoneOtherIf other, please describe: *Outcomes of these treatments: *Name and Address of other doctor(s) who have treated you for your condition: *Is there anyone you would like us to keep informed regarding your treatment at the office? *YesNoPlease specify name and address:Date of Last (MM/DD/YYYY)--Physical Exam? *Spinal X-Ray? *MRI, CT-Scan, Bone Scan? *Chest X-ray? *Any related symptoms/conditions: *Any recent infections? *YesNoAny fever or chills? *YesNoAny dizziness? *YesNoAny change in bowel or bladder habits? *YesNoHave you ever suffered from? *BackachesHeadachesDizzinessNumbnessArthritisHerniated DiskMultiple SclerosisThyroid ProblemsDiabetesHerniaHeart TroubleAsthmaSinus TroubleBleeding DisordersParkinson's DiseaseAnemiaAnxietyCancerOsteoporosisEpilepsyMigrainesRheumatic FeverStrokePneumoniaTuberculosisHypertensionProstate ProblemHigh CholesterolPsychiatric CareOtherIf other, please describe: *Has a physician treated you for any other condition(s) in the past 12 months? *NoYesIf yes, please explain: **Women Only* Is there any change you may be pregnant? *NoUncertainYesIf yes, what is your due date? *Exercise? *NoneModerateDailyVigorousActivities: *Work Activity: *SittingStandingLight LaborHeavy LaborOtherIf other, please describe: *Habits: *SmokingAlcohol UseCoffee/CaffeineWhat is your stress level? 1 being stress-free, 10 being max Selected Value: 1 Stress Management Techniques Used: *Please describe for us any hospitalizations, serious illnesses, falls, broken bones, or surgeries you have had. (include time of year, hospital stayed, and reason for stay) *Please list your prescribed medications, over-the-counter medications, herbs, vitamins/supplements, and inhalers. (Please include dosages, names, frequency of use, and what it's prescribed for)Please provide details of any known allergies (eg. Latex, foods, medications, etc.) and the reactions you have to them: *Please help us to identify your potential health risks by placing a check in any column below that applies to you or your blood relatives. *AIDS/HIV *SelfParentGrandparentArthritis *SelfParentGrandparentBleeding Disorders *SelfParentGrandparentCancer *SelfParentGrandparentEndocrine/Glandular (eg. Diabetes, thyroid) *SelfParentGrandparentHepatitis *SelfParentGrandparentImmune *SelfParentGrandparentStroke/TIA *SelfParentGrandparentCirculatory Problems (blood, heart) *SelfParentGrandparentEar, Nose, Throat *SelfParentGrandparentHigh Blood Pressure *SelfParentGrandparentHeart Problems *SelfParentGrandparentNeurological (brain, nerves) *SelfParentGrandparentGastrointestinal (stomach, intestines) *SelfParentGrandparentMuscle/Joint/Bone *SelfParentGrandparentGenitourinary (Kidney, Prostate, Urinary) *SelfParentGrandparentPsychological *SelfParentGrandparentRespiratory (Lungs, Breathing) *SelfParentGrandparentSkin *SelfParentGrandparentSubmit