Patient Intake Form | Health First Chiropractic

First name

Last name

DOB

Day

Month

Year

Age

Email

Address

Telephone (home)

Telephone (work)

Number of children

Occupation & Employer

Marital status

Spouse's Name

Spouse's Occupation & Employer

Spouse's Health Status

Date of Birth for Insured Spouse

Emergency Contact - Name & Phone

Nature of Injury

Automobile

Work

Other

Please Describe

Date of Injury

Date Symptoms Appeared

Have you ever had same condition? If yes, when

List other practitioners seen for this injury/condition

Have you ever been under chiropractic care? If yes, please describe

Name & phone of party responsible for payment

Do you have health insurance? Add Insurance company name

Contact person & Phone

Claim #

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?

Yes

No

Have you had X-rays taken? If Yes, where?

What medications are you taking and for what conditions (Please list dosage and amounts, etc).

What vitamins, minerals, or herbs do you currently take? (Please list for what condition, dosage, and frequency).

Have you ever experienced any of the following? Please select all that apply.

Please briefly describe any injuries or trauma selected above.

Have you ever been hospitalized or had surgery? Please briefly explain, including the reason and approximate date.

Family members - Present and past health conditions (Example: heart disease, cancer, diabetes, arthritis, etc.)

How do your symptoms affect you?

I experience pain every day

My symptoms interfere with my daily activities

Pain wakes me up at night

My symptoms are worse at certain times of the day

Changes in weather affect my symptoms

None of the above

Do you wear orthotics?

Yes

No

Do you take any vitamins or supplements? Please list them.

What activities aggravate your symptoms?

Please describe your typical intake of water, coffee, soft drinks, salty foods, sugary foods, artificial sweeteners, and appetite.

Please describe your use of alcohol, tobacco, or recreational drugs. If none, write “None.”

Please describe your typical exercise level and sleep habits.