New Patient Form File

					Name:                                      ______                _____      Date: ______________________
Address: ______________________________________________________ Postal Code: _____________________
Phone (Home): ____________________ (Work): _______________________ (Cell): _______________________
Health Card Number (6 digit):
Age: _______      Birth Date: (D/M/Y) ___________________     Height: ___________    Weight: _____________
Occupation: ___________________________________Employer: _______________________________________
Email: __________________________________________ Are you pregnant: Yes / No (circle)
Status:   S   M   W   D     Name of Spouse: _____________________________ # of children: ___________
Who referred you here or how did you learn of our office? _________________________________________


ABOUT YOUR HEALTH:
The human body is designed to be healthy. Throughout life, events occur which damage your health
potential. This case history will uncover the layers of damage, especially to your nerve system, that
have resulted in poor health. Following your exam, your chiropractor will outline a course of care to
begin to correct these layers of damage and recover your innate health potential.


CHIROPRACTIC HISTORY:
Have you been to a chiropractor before? Yes / No             Date of last visit: _________________________
Name of last chiropractor: _______________________________________________________________________


MAJOR HEALTH COMPLAINT:

What condition brought you to our office? _______________________________________________________
On a scale of 1-10 (10 being severe), how bad is the problem? _____ / 10
When did it start? ___________________________      How? ___________________________________________
Is it □ getting better □ getting worse     □ staying the same?
How would you describe the problem? __________________________________________________________
Are you taking medication for this condition? Yes / No
If yes, which medication: _______________________________________________________Dose: ___________
Please list ALL other medications you are currently taking: _________________________________________

Most people have had literally dozens of impacts/stresses that can cause spinal misalignments (subluxations).
When was your most recent auto accident? _________ Front /side /rear-end collision? _____
What sport or recreational activities do you do? ___________________________________________
Describe your most recent stress or strain during these activities? ___________________________
When was your most recent stress or strain during these activities? __________________________
Is there any other injury that you have had, minor or major, that we should know about?
__________________________________________________________________________________________
PLEASE CHECK OFF ALL YOU HAVE EXPERIENCED IN THE LAST YEAR:
□Headaches           □Neck pain                □Middle back pain         □Lower back pain
□Dizziness           □ Stiff neck              □Breathing difficulty     □Pins & needles in legs
□Loss of hearing     □Cold hands               □Stomach upset            □Numbness in toes
□Fainting            □Pins & needles in arms   □Cold feet                □Diarrhea
□Numbness in fingers □Heartburn                □Menstrual Irregularity   □Menstrual pain
□Depression          □Ulcers                   □Seizures                 □Sleep problems
□Sinus problems      □Loss of taste            □Hot flashes              □Constipation
□Ringing in ears     □Fatigue                  □Problem urinating        □Jaw problems
□Cancer              □Heart Disease            □Diabetes                 □Loss of balance

Please fill out the following information on the three most serious conditions you listed above,
not including your major health complaint:
Condition 1: _______________________________________
On a scale of 1-10 (10 being severe), how bad is the problem? ___ / 10
When did it start? _________________________________ How? _______________________________
Is it    □ getting better □ getting worse    □ staying the same?
How would you describe the problem? ___________________________________________________
Are you taking medication for this condition? Yes / No
If yes, which medication: ________________________________________________Dose: ___________
Condition 2: _______________________________________
On a scale of 1-10 (10 being severe), how bad is the problem? ___ / 10
When did it start? _________________________________ How? _______________________________
Is it    □ getting better □ getting worse    □ staying the same?
How would you describe the problem? ___________________________________________________
Are you taking medication for this condition? Yes / No
If yes, which medication: ________________________________________________Dose: ___________
Condition 3: _______________________________________
On a scale of 1-10 (10 being severe), how bad is the problem? ___ / 10
When did it start? _________________________________ How? _______________________________
Is it    □ getting better □ getting worse    □ staying the same?
How would you describe the problem? ___________________________________________________
Are you taking medication for this condition? Yes / No
If yes, which medication: ________________________________________________Dose: ___________




                   Lindenwoods Chiropractic 9-1080 Waverley St 474-1159

				
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