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Contact
SCHEDULE NOW
770.416.9995
GET DIRECTIONS
PATIENT ACCESS

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New Patient Intake Form

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Your Name*

First Middle Last

Email*

Age*

Sex*

Weight*

Height*

Martial Status*

Children?*

How Many?*

Resides With?*

Occupation*

Emergency Contact Name*

Emergency Phone Number*

# hours per week currently working

How did you hear about us?

Please indicate for which body region you are seeking treatment:

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Please describe what area you chose and the issue you're here to treat:*

If none, please type "N/A"

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Side of Body*

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Please describe what area you chose and the issue you're here to treat:*

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Please indicate for which body region you are seeking treatment:

Front of Body*

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Please describe what area you chose and the issue you're here to treat:*

If none, please type "N/A"

When did your symptoms begin?*

How often do your symptoms occur?*

Other

Provide additional details regarding symptoms

Was your pain a result of an accident or injury?*

If yes, please explain:*

Provide details regarding accident/injury

Using a scale of 0-10 (10 being extreme) how would you rate your pain?

At Present*

Please enter a number from 0 to 10.

At Best*

Please enter a number from 0 to 10.

At Worst*

Please enter a number from 0 to 10.

What activities/positions aggravate your condition?*

What activities/positions relieve your condition?*

Have you had any treatment associated with this condition? (Ex. OTC or Rx medications, physical therapy, chiropractic care, surgical consult, injections)*

If yes, please list the dates and treatments:*

Have you ever been diagnosed with or had any of the following? (Please check all that apply)*

Osteoarthritis

Chronic headaches

High cholesterol

Recent unexplained weight loss

Joint replacement

Irregular heartbeat

Metal Implants/Pacemaker

Asthma/COPD

Lupus

Diabetes

Head injury/Concussion

Blood clots

Cancer

Stroke/M

Osteoporosis

High blood pressure

Seizure disorder

Other

N/A

Other Diagnosed

Please indicate whether you are RIGHT or LEFT handed:*

Do you smoke?*

How much?*

Do you drink alcohol?*

How often?*

Do you drink caffeinated beverages?*

How many per day?*

How much water do you drink per day?*

Do you have a primary care doctor?*

Doctor's Name and Address:*

Do you have a chiropractor?*

Chiropractor's Name and Address:*

Have you been hospitalized in the past five years?*

If yes, please explain what you were hospitalized for:*

Have you ever had surgery?*

If yes, please list the type of surgery and year:*

Are you currently pregnant or trying to get pregnant?*

Are you currently taking any medications on a daily basis?*

If yes, please list medication, dosage, and frequency:

Do you have any allergies to medicine?*

If yes, please list the allergies and reaction:*

Are you currently taking any supplements on a daily basis?*

If yes, please list the supplement names:*

What are your goals while receiving treatment in our office and the timeframe:*

Consent

I understand and agree that the health and accident policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that this office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to this office will be credited to my account upon receipt. However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will be immediately due and payable.

Date*

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