New Patient Registration Form Name * First Name Last Name Gender Male Female Date of Birth MM DD YYYY Age City/State/Zip Phone (###) ### #### Email Occupation/Employer's Name and Address Relationship Status Single Married Divorced Widowed Spouse's Occupation Number of Children Referred By As a child, did you have any illnesses? Yes No Unsure As a child, did you have any serious falls? Yes No Unsure As a child, did you play sports? Yes No Unsure As a child, did you have any surgery? Yes No Unsure As a child, was there any prolonged use of medicine, such as antibiotics or inhalers? Yes No Unsure As a child, did you suffer any other traumas, physical or emotional? Yes No Unsure As a child, were you involved in any car accidents? Yes No Unsure Do/did you smoke? Yes No Do/did you drink alcohol? Yes No Have you been in any accidents? Yes No Have you had any surgery? Yes No Do/did you play any sports? Yes No Describe your occupational stress level None=0 | Extreme=10 Describe your personal stress level None=0 | Extreme=10 Weight How many cups of coffee per day? How many times a day do you eat? What percentage of your daily diet consists of fruits and vegetables? How many days per week do you exercise? For approximately how many hours? At what intensity? Low=1 | High=5 How many hours do you sleep per night? What is the quality of your sleep? Bad=1 | Good=5 Do you feel rested when you wake? Yes No Reason for visit Briefly describe your symptoms How did your symptoms start? Average pain intensity No Pain=1 | Worst Pain=10 How often do you experience your symptoms? 1 Constantly (76% - 100%) 2 Frequently (51% - 75%) 3 Occasionally (26%-50%) 4 Intermittently (0% - 25%) Have you ever received chiropractic care? Yes No Other doctors you have seen for this problem Please check all symptoms you have ever had, even if they do not seem related to your current condition Back Pain Cold Feet Cold Hands Cold Sweats Constipation Depression Diarrhea Dizziness Fainting Fever Headaches Heartburn Hot Flashes Irritability Loss of Balance Loss of Smell Loss of Taste Menstrual Irregularity Menstrual Pain Mood Swings Neck Pain Nervousness Numbness in Fingers Numbness in Toes Pins and Needles in Arms Pins and Needles in Legs Problems Urinating Ringing in Ears Sensitive Eyes Sleeping Problems Stiff Neck Ulcers Upset Stomach List any medications you are taking Please list below any health conditions or concerns you may have about a family member Children, Spouse, Mother, Father, Brother, Sister, Other Thank you!
