New Patient Health History Form
In order to provide you the best possible care, please complete this form
and bring it to your first appointment. All information is strictly CONFIDENTIAL.
Patient Data
First Name Last Name Date Email*
* Your email will NOT be shared with any 3d parties, and is used for occasional office announcements and promotions.
Mailing address
Address City State Zip
Telephone (Work) (home) Referred By
Age Birth Date Social Security # Number of Children
Occupation Employer
Marital Status Spouse's Name Spouse's Occupation
Spouse's Employer Spouse's Health Status
Emergency Contact Phone
Current Complaints
Nature of Injury:
Please describe:
Date of Injury Date symptoms appeared
Have you ever had same condition? If yes, when?
List of other practitioners seen for this injury/condition
Have you ever been under chiropractic care?
If yes, please describe
Insurance Information
Name of party responsible for payment Phone
Do you have health insurance? Name of company
* If an auto accident, please provide:
Insurance Company Name Contact Person
Phone: Claim #
Signatures
Name of the insured ________________________________________________________________________
I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier
and myself. I understand and agree that all services rendered to me and charged are my personal
responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for
professional services rendered to me will be immediately due and payable.
Patient’s signature _______________________________________________ Date ____________________
Spouse’s or guardian’s signature __________________________________ Date ____________________
© Copyright 2005 ChiroMatrix
Automobile*
Work
Other
No
Yes
No
Yes
No
Yes
Medical History
Have you been treated for any conditions in the last year?
If yes, please describe
Date of last physical exam Is there a chance that you are pregnant?
Have you had X-rays taken? If Yes, where?
What medications are you taking and for what conditions (Please list dosage and amounts, etc)l
What vitamins, minerals, or herbs do you currently take? (Please list for what conditions, dosage, and frequency).
Have you ever: No Yes Briefly Explain
Broken bones?
Been hospitalized?
Been in an auto accident?
Had Sprains/Strains?
Been struck unconscious?
Had surgery?
Family History
Family Members - Present and past health conditions (Example: heart disease, cancer, diabetes, arthritis, etc.)
Do you experience pain every day?
Do your symptoms interfere with daily life?
Does pain wake you up at night?
Are your symptoms worse during certain times of the day?
Do changes in weather affect your symptoms?
Do you wear orthotics?
Do you take vitamin supplements?
What activities aggravate your symptoms?
Habits None Light Moderate Heavy
Alcohol
Coffee
Tobacco
Drugs
Exercise
Sleep
Appetite
Soft Drinks
Water
Salty Foods
Sugary Foods
Artificial Sweeteners
© Copyright 2005 ChiroMatrix
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Have you ever suffered from:
Alcoholism
Allergies
Anemia
Arteriosclerosis
Arthritis
Asthma
Back Pain
Breast Lump
Bronchitis
Bruise Easily
Cancer
Chest Pain/Conditions
Cold Extremities
Constipation
Cramps
Depression
Diabetes
Digestion Problems
Dizziness
Ears Ring
Excessive Menstruation
Eye Pain or Difficulties
Fatigue
Frequent Urination
Headache
Hemorrhoids
High Blood Pressure
Hot Flashes
Irregular Heart Beat
Irregular Cycle
Kidney Infection
Kidney Stones
Loss of memory
Loss of balance
Loss of smell
Loss of taste
Lumps In Breast
Neck Pain or Stiffness
Nervousness
Nosebleeds
Pacemaker
Polio
Poor Posture
Prostate Trouble
Sciatica
Shortness of breath
Sinus Infection
Sleep problems or Insomnia
Spinal Curvatures
Stroke
Swelling of ankles
Swollen Joints
Thyroid Condition
Tuberculosis
Ulcers
Varicose Veins
Venereal Disease
Other:
Please use the following letters to indicate TYPE and
LOCATION of the symptoms you currently are experiencing.
A=Ache O=Other
B=Burning P=Pins & Needles
N=Numbness S=Stabbing
© Copyright 2005 ChiroMatrix
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