New Patient Application

Name

Address

Phone Home

Cell

Work Number

Occupation

Employer

E-Mail

Date of Birth

Social Security #

Marital Status

Spouse's Name

Emergency Contact Name

Emergency Contact Number

Out of Town Address

Race:   
American Indian or Alaska Native  
Asian  
Black or African American  
White(Caucasian)  
Native Hawaiian or Pacific Islander  
I Decline to Answer  

Who is your current Medical Doctor?

May we contact them?
Yes   No  

Medication Name

Dosage & Frequency

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Medication Name

Dosage & Frequency

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Medication Name

Dosage & Frequency

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Medication Name

Dosage & Frequency

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Medication Name

Dosage & Frequency

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Medication Name

Dosage & Frequency

---

Medication Name

Dosage & Frequency

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Medication Name

Dosage & Frequency

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Medication Name

Dosage & Frequency

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Medication Name

Dosage & Frequency

Surgeries / Hospitalizations

Major Illnesses

Immunizations

Reported Tests (MRI. X-Ray. Ect.)

Heart Disease

Arthritis

Cancer

Stroke

Diabetes

Heart Disease

Arthritis

Cancer

Stroke

Diabetes

Cause:    Unknown  
Accident
(If auto fill out auto accident form as well)

Prior History   
None  
On/Off For Months  
Years  

Side:   
Left   Right   Both  

Any Change?   
No Change  
Improving  
Getting Worse  

Quality:   
Achy  
Burning  
Dull  
Sharp  
Stiff  
Throbbing  
Other  

Frequency:   

Constant  
Frequent  
Intermittent  
Occasional  
Other  

Nothing

Driving

Lifting

Movement

Resting

Sleeping

Sitting

Standing

Walking

Nothing

Cold/Heat

Medications

Movement

Resting

Sleeping

Walking

Chiropractic

Headaches?   
Yes   No  

If yes, Location

How often do they occur and how long do they last?

Name of Doctor

Treatments Given

Feet

Inches

Weight

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