New Patient

New Patient

Patient’s First Name

Patient’s Last Name

Date

Address

City

Postal code

Home Phone

Cell Phone

Email *

Social Security No

Job Title

Work Phone No

Employer Name

Date of Birth Patient

Age

Gender

Handedness?

Weight

Height

Marital Status

Spouse’s Name

Spouse’s Date of Birth

Person responsible for this account

Employer Phone No

Children names and ages

Drivers License No

Have you ever had chiropractic care before?

For what problem?

Were the results satisfactory?

Major complaints and symptoms - please be as specific as you can. Ask the doctor or nurse for help if you need assistance in filling out this section.

How do you believe your problem (pain) began?

When did you first notice this problem/pain?

Have you lost any work?

Day and date you last worked

Have you ever had this condition before or a similar condition?

When?

What positions or activities aggravate your condition?

What positions or activities relieve your condition?

Have you been treated by a medical physician for this ailment?

Where?

Describe the type of treatment

Diagnosis of previous physician

Length of time under care

Results

Will this be covered by any insurance company? Major Medical

Auto

Blue Cross/Blue Shield

Workers' Compensation

Medicare

Have you ever been in any accidents, auto, fall down stairs, fall from ladder, etc. (even as a child)?

Are you allergic to anything you are aware of ?

Are you presently taking any medication (aspirin included)?

If yes, name them

Have you ever broken any bones? (fractures)

Any dislocations?

What operations have you had?

Year

Give date you have had any of the following? (if exact date is unknown give approximate)

Blood tests

Urinalysis

X-Ray examination

Other special treatment

At what hospital or office were these tests taken?

Name of doctor who ordered tests

Date of last menstrual period

Do you have any reason to believe that you may be pregnant?

Do you have any health problems not listed above?

Do you faint easily?

Do you take vitamins?

If Yes, please list them

Habits: (please check)

Cigarettes

Cigarettes Quantity

Coffee

Coffee Quantity

Alcohol

Alcohol Quantity

Tea

Tea Qunatity

Hobbies

Have you been treated for any health condition by a physician in the past year?

If yes, what condition?

Have you lost or gained weight in the past year?

Use this space for any additional information you wish to discuss

Have you had or do you now have any of the following symptoms which are or have been

of significant distress to you? Please indicate with the letter "N" if you have these conditions

now or "E" if you ever had these conditions.

Headaches

Neck Pain

Stiff Neck

Sleeping Problems

Back Pain

Nervousness

Tension

Irritability

Dizziness

Shoulder/Neck/Arm Pain

Pins & Needles in Arms

Pins & Needles in Legs

Numbness in Fingers

Numbness in Toes

High Blood Pressure

Difficulty Urinating

Allergies

Weakness in Arms

Weakness in Legs

Shortness of Breath

Fatigue

Depression

Lights bother eyes

Loss of Memory

Ears Ring

Face Flushed

Buzzing in Ears

Loss of Balance

Fainting

Loss of Smell

Loss of Taste

Diarrhea

Feet Cold

Hands Cold

Arthritis

Muscle Spasms

Frequent Colds

Stomach Upset

Constipation

Cold Sweats

Fever

Sinus Problems

Diabetes

Hemorrhoids

Leg Cramps

Colitis

Gall Bladder

Indigestion

Belching

Vomiting

Shoulder Pain

Swelling Joints

Hay fever

Menstrual Difficulties

Ready to Begin Your Healing Journey?

Start with a consultation and get the answers your brain and body need.

Image of a chiropractic office with a welcoming environment, featuring a treatment table, anatomical models, and healthcare materials, relevant to Elkton Chiropractic Neurology's patient care and evaluation process.

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