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New Patient Intake Form - Schmidt Chiropractic Center

Schmidt Chiropractic Center

New Patient Intake Form

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Personal Information

Patient Name *

Date

Parent/Guardian Name (if patient is a minor)

Address *

City *

State *

ZIP Code *

Home Phone

Cell Phone *

Work Phone

Email *

Date of Birth *

Marital Status

Sex

Age

Number of Children

Social Security Number

Driver's License #

Occupation

Employer

Employer Address

Employer Phone

Spouse Name

Spouse's Occupation

Spouse's Employer

Spouse's Employer Phone

Emergency Contact

Emergency Contact Name *

Relationship *

Address

Phone *

Referred By

Current Health Conditions

Purpose of This Appointment *

How Did It Happen?

When Did This Condition Start?

Is It Getting Progressively Worse?

What Activities Aggravate Your Condition?

What Activities Lessen Your Condition?

Is Condition Worse During Certain Times of Day?

Is This Condition Interfering With:

Work Sleep Daily Routine

Other Doctors Seen for This Condition

Type of Treatment Received

Results

Are You Currently Pregnant or Trying to Get Pregnant?

Lifestyle & Habits

Alcohol: Type

Amount/Frequency

Smoking: Packs Daily

How Long?

Interested in Stopping?

Caffeine: Coffee/Soda Daily

Exercise Routine

Sleep Issues:

Difficulty Falling Asleep Continuity Disturbances Early Morning Awakening Daytime Drowsiness

Diet: Salt Intake

Fat Intake

Medications & Allergies

Current Medications

Drug Allergies

Medical History

Please check any conditions that apply to you:

Ringing in Ear Ear Infections (frequent) Dizziness/Fainting Failing Vision Eye Infections Nose Bleeds Sinus Trouble Sore Throat (frequent) Hay Fever/Allergies Pneumonia Bronchitis/Chronic Cough Asthma/Wheezing Chest Pain High Blood Pressure Heart Murmur Swollen Ankles Leg Pain (walking) Varicose Veins/Phlebitis Loss of Appetite Difficulty Swallowing Indigestion/Heartburn Persistent Nausea/Vomiting Peptic Ulcers Abdominal Pain (chronic) Gall Bladder Trouble Jaundice/Hepatitis Change in Bowel Habits Diarrhea Constipation Diverticulosis Crohn's/Colitis Bloody or Tarry Stools Hemorrhoids Hernia Urine Infections (frequent) Blood in Urine Urination Overnight >2x Painful Urination Kidney Stones Tremor/Hands Shaking Muscle Weakness Numbness/Tingling Headaches (frequent) Arthritis/Rheumatism Osteoporosis Back Pain (recurrent) Bone Fracture/Joint Injury Gout Foot Pain/Cold Numb Feet Rashes/Hives Psoriasis/Eczema Nervousness/Depression Memory Loss Moodiness (excessive) Chronic Fatigue Weight Loss (recent) Anemia/Bruise Easily Cancer Diabetes Thyroid Disease Convulsions/Seizures Stroke Lactose Intolerance

Other Conditions Not Listed

Hospitalizations

Previous Hospitalizations (Date & Reason)

Family History

Please indicate if any blood relatives have had the following conditions:

Diabetes Cancer Blood Disease Glaucoma Epilepsy Rheumatoid Arthritis Tuberculosis Gout High Blood Pressure Heart Disease Back Problems

Family Health Details (optional)

Authorization

I hereby authorize Schmidt Chiropractic Center to release any information required in the course of my examination or treatment necessary to satisfy medical insurance claims. I certify that the information provided above is accurate and complete to the best of my knowledge.

Signature (Type Full Name) *

Date *

I agree to the terms above and certify that this information is accurate *

Your information is protected and will only be used for healthcare purposes.

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