New Patient Form-Single Page

This is a detailed Health Information Form that is designed to better help us understand your specific requirements. Please invest a few minutes now and save yourself from having to revisit this form with the intake assistant during your first appointment. Fields with a * are required.

    New Patient Information (*=Required Field)


















    MaleFemale

    SingleMarriedSeparatedDivorcedWidowed


















    SpouseFamilyFriendOther








    SpouseFamilyFriendOther


    Insurance Information


    YesNo


    If yes please bring insurance card to the office on your first visit.

    Auto Insurance Information


    Auto InsurancePersonal Injury Protection (PIP)Uninsured MotoristMed Pay















    Third Party Liability (if applicable)










     If you do not have the information of the person at fault, please bring the third party liability information with you on your next visit. Thank you! 



    Review of Symptoms


    N/AFaintingLow LibidoPoor AppetiteFatigueSudden Weight GainSudden Weight LossWeakness

    N/AAsthmaApneaEmphysemaHay FeverShortness of BreathPneumonia

    N/AHigh Blood PressureLow Blood PressureHigh CholesterolPoor CirculationAnginaExcessive Bleeding

    N/AAnorexia/BulimiaUlcerFood SensitivitiesHeartburnConstipationDiarrhea

    N/AKidney StonesInfertilityBedwettingProstate IssuesErectile DysfunctionPMS Symptoms

    N/ASkin CancerPsoriasisEczemaAcneHair LossRash

    N/ABlurred VisionRinging in EarsHearing LossChronic Ear InfectionLoss of SmellLoss of Taste

    N/AThyroid IssuesImmune DisordersHypoglycemiaFrequent InfectionSwollen GlandsLow Energy


    History

    Mother's Family History




    GoodFairPoorN/A

    NaturalIllnessOtherN/A-Still Living

    CancerStrokeHeart DiseaseDiabetesAuto-ImmuneN/A


    Father's Family History





    GoodFairPoorN/A


    NaturalIllnessOtherN/A-Still Living

    CancerStrokeHeart DiseaseDiabetesAuto-ImmuneN/A


    Social History
















    Past Medical History


    N/AAIDSAlcoholismAllergiesArteriosclerosisCancerChicken PoxDiabetesEpilepsyGlaucomaGoiterGoutHeart diseaseHepatitisHIV PositiveMalariaMeaslesMultiple SclerosisMumpsScarlet feverSexually transmitted diseasePolioRheumatic feverStrokeTuberculosisTyphoid feverUlcer





    Any surgeries PRIOR to injury?


    N/AAppendix removalBypass surgeryCancer relatedCosmetic surgeryEye surgeryHysterectomyPacemakerTonsillectomySpinal SurgeryJoint Surgery






    Medications & Allergies


    Please list below all prescription, over-the-counter or natural supplements you are taking




    Are you allergic to any medications?


    YesNoNot Sure

    If yes, please list


    Dominant Hand



    RightLeftAmbidextrous (both)



    ACCIDENT INFORMATION



    Select The Type of Accident You Had


    Auto AccidentSlip & Fall/Personal Injury



    "PERSONAL INJURY or SLIP/FALL"


    YesNo


    Describe How and Where the injury occurred:











    FallSlipTripOther

    ForwardBackwardsLeftRightN/A





    YesNo





    YesNoN/A




    YesNo

    YesNoNot Sure


    Upload INJURY Pictures | Filetypes:jpeg|png|jpg File size limit:5242880 Bytes


    "MOTOR VEHICLE ACCIDENT (Patient)"


    Yes (Bring Copy)No


    Motor Vehicle Information






    Rear-endedFront-end impactedT-Boned Driver SideT-Boned Passenger SideRolloverSide Impact Driver SideSide Impact Passenger SideOther

    FrontSideRearOther



    DryRainIceFogOther

    MorningNoonAfternoonEveningOvernight






    MECHANISM OF INJURY





    DriverFront PassengerLeft-Rear PassengerMiddle-Rear PassengerRight-Rear PassengerOther


    YesNo

    YesNo

    YesNo

    Straight AheadLeftRightUnsure

    YesNoUnsure



    Upload MOTOR VEHICLE ACCIDENT Pictures | Filetypes:jpeg|png|jpg File size limit:5242880 Bytes


    Upload INJURY Pictures | Filetypes:jpeg|png|jpg File size limit:5242880 Bytes


    Post-Injury Questionnaire


    YesNo

    YesNo



    Immediately AfterA few hours afterOne day laterA few days laterCan't Remember

    MRICT ScanX-RaysTests conducted Lying DownTests Conducted Standing



    YesNo

    YesNo





    SINCE THE ACCIDENT


    Prescription medicationOTC medicationHomeopathic remediesSurgeryAcupunctureChiropractic careIceHeatMassagePhysical TherapyRestPain Relief CreamsWearing a support/braceOtherNone





    ACTIVITIES OF DAILY LIVING


    SittingRising out of chairStandingWalkingLying downBending overClimbing stairsDriving a carTurning headHousehold choresLifting objectsReaching upShowering or bathingGetting dressedLove lifeSleepConcentratingExercisingOtherNone





    Work Status


    YesNo




    YesNo

    StudentRetiredDisabledHomemaker


    YesNo




    A doctor took you off workYou took yourself off workYou had no transportation after the accidentYour boss took you off workYou were fired or lost your job as a result of this accidentOther




    YesNoN/A

    YesNoN/A


    YesNoN/A






    Functional Rating Index

    In order to properly assess your condition, we must understand how much your neck and/or back problems have affected your ability to manage everyday activities. For each item below, please select each item which most closely describes your condition right now.

    Rate Your Pain Intensity

    Rate Your Sleeping

    Personal Care (washing, dressing, etc.)

    Travel (driving, etc.)

    Working

    Recreation

    Frequency of Pain

    Lifting

    Walking

    Standing

    Any information that is not provided while filling out this form will need to be reviewed at the clinic on your first visit. By providing this information at this time, your initial appointment intake process will not be so lengthy. Your doctor will need a health history to complete the initial exam.

    Additional forms will need to be signed when you arrive at the clinic on your first visit.
    Please bring a photo ID and any previous care information related to your accident if applicable.
    Thank you!