NP - New Chiropractic Patient Intake

New Chiropractic Patient Intake

Please complete this form prior at least 24 hours prior to your appointment. Feel free to call if you have problems with this form 919-322-4383. We look forward to seeing you soon!
Personal Information
Name *

First Name Last Name
Please enter your date of birth *

Month Day Year
If your preferred name is different than your given name, please enter below:
Please enter your social security number *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Email *
example@example.com
Phone Number *

Area Code Phone Number
Who referred you to our office? *

a friend my doctor Google/internet search my health insurance
If referred by friend, family or your physician, please provide their name:
Please provide a contact in case of emergency *

First Name Last Name
Emergency contact phone number *

Area Code Phone Number
Primary care physician

First Name Last Name
Primary care physician phone number

Area Code Phone Number
Health insurance policy information

Please complete this section entirely. If you are self pay (do not participate with a health insurance plan) please select self pay and move to the next section.
Please select the name of your health insurance provider *

Blue Cross Blue Shield Cigna Medcost United Healthcare Aetna Medicare No insurance / Cash patient
Subscriber ID / Member ID
This is generally listed on the front of your insurance ID card and may be alpha numeric. Please include all characters listed including any listed suffix (01,02,03, etc)
Group number
Please list your relationship to the insured *

I am the policy holder My spouse is the policy holder I am a dependent of the policy holder No insurance / Cash patient
Provider services phone number (usually listed on the back of the ID card)

Area Code Phone Number
If you are not the policy holder, please enter the policy holder's name

First Name Last Name
Policy holder's date of birth (mm/dd/yyyy)
Lifestyle history

Please complete the following fields to the best of your ability. This information will help us with your case and should not be left blank.
Do you use tobacco products?

no Yes occasionally
How often to you consume alcoholic drinks?

rarely / never 1-3 drinks per week 3-5 drinks per week over 6 drinks per week
Which statement best describes your eating habits?

I eat fast food regularly (3+ times per week) I eat out sometimes and make healthy choices I eat clean (organic, whole foods most of the time)
Which statement best describes your exercise habits

I exercise regularly and frequently (3+ times per week on a regular basis) I exercise regularly but in-frequently (1-2 times per week on regular basis) I exercise every once in a while I don't exercise
Please list any prescription medications you are currently taking
Please list any supplements and over the counter medications you currently take
Current condition information

Please use the following fields to describe what brings you into our office today.
I am seeking pain relief I am not currently experiencing pain, I am seeking services to improve overall function
Please list your health concern(s) *
Please use the drawing tool to circle your area of complaint (s) From left to right the bodies represent Back, Front and Side positions
The quality of my pain listed above is characterized as

burning stabbing dull/ache stiff pins and needles / tingling
This pain is

constant on and off
Does this pain radiate/shoot to other areas of the body?

yes no
If it radiates, to which area does your pain travel?
If you answered yes the the last question (your pain radiates), please select which areas are affected

shoulder / arm / hands / fingers buttocks / leg ankle / foot right left both right and left
Please list all things which make your pain better

ice heat rest movement / position change sitting standing stretching Rx medication OTC medication
Please list all the things which make your pain worse

sitting standing movement / position change walking lying down sleeping heat

Please indicate how your condition impacts the following activities of daily living

	painful	some pain	not affected
bending
lifting
stairs
sitting
standing
walking
exercising
housework
kneeling

Please list any other providers who have treated this condition

my primary care physician orthopedic doctor massage therapist physical therapist another chiropractor
Please list any imaging you have had in the last three months

spinal xray spinal MRI
Is your pain a result of any of the following?

motor vehicle accident personal injury worker's compensation none of the above
Health history

Please indicate any past or present conditions listed below. Check all that apply.
General: *

recent unintentional weight loss fever extreme fatigue none in this category
Musculoskeletal *

broken bones previous surgery (please explain in next section) none in this category
Neurological *

numbness or tingling sensations loss of feeling dizziness or lightheaded frequent or recurrent headaches head injury / concussion none in this category
Gastrointestinal *

loss of apetite bloody stool constipation diarrhea nausea or vomitting regular abdominal pain / bloating none in this category
Cardiovascular / heart *

chest pain rapid or heartbeat changes blood pressure regulation problems high cholesterol swelling of ankles and feet none in this category
Respiratory *

difficulty breathing persistent cough asthma coughing blood none in this category
Eyes / vision *

blurred or double vision eye disease or injury wear glasses / contacts none in this category
Genitourinary *

kidney stones burning / painful urination frequent urination urinary leakage / bed wetting blood in urine none in this category
Endocrine, hematologic, lymphatic *

thyroid problems diabetes cold hands / feet immune system disorder none in this category
Skin and breasts *

rash / itching non-healing sores breast pain breast lump none in this section
For women only: Are you pregnant?

yes no it's possible
If yes, what is your estimated date of delivery?

- Month - Day Year
Date Date Picker Icon
Do you have an immediate family history of any of the following? (check all that apply) *

cancer heart disease stroke none of the above
Please list any surgeries in the field below. List surgery type and year performed.
HIPAA Privacy Practices Below
I have reviewed the HIPAA Privacy Practices for Gard Wellness Center (above) *

Clear
You're done! Thank you for completing this form, click 'Submit' below and we'll receive your information. We look forward to helping you life life well!
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New Chiropractic Patient Intake

Personal Information

Health insurance policy information

Lifestyle history

Current condition information

Health history