Welcome

New Patient Information
  1. First Name
  2. Middle Name
  3. Last Name
  4. Preferred Name
  5. Driver's License / ID
  6. Gender
  7. Date of Birth
  8. Status
Contact Information
  1. Address
  2. City
  3. State
  4. Postal Code
  5. Home Phone
  6. Mobile Phone
  7. Cell Phone Carrier
  8. Email Address
Employment
  1. Were you employed at the time of the accident?
  2. Are you currently employed?
  3. Employment Status
  4. If other employment status, please describe
  5. Employer’s Name
  6. Employer’s State
  7. Work Phone
  8. Employer’s Address
  9. Employer’s City
  10. Employer’s Postal Code
Emergency Contact #1
  1. Name
  2. Relationship
  3. Phone
Emergency Contact #2
  1. Name
  2. Relationship
  3. Phone
Health Insurance
  1. Do you have health insurance?
Auto Insurance
  1. Check all insurance that you have:
    • Auto Insurance
    • Personal Injury Protection (PIP)
    • Uninsured Motorist
    • Med Pay
  2. Name of Insured
  3. Name of Insured Phone Number
  4. Insurance Company
  5. Insurance Company Phone Number
  6. Policy
  7. Adjuster
Third Party Liability (if available)
  1. Name of Insured
  2. Name of Insured Phone Number
  3. Insurance Company
  4. Insurance Company Phone Number
  5. Policy
  6. Adjuster
Review of Systems
  1. Please check any condition you have.
  2. Constitutional
    • Fainting
    • Low Libido
    • Poor appetite
    • Fatigue
    • Sudden weight
    • Weakness
    • None
  3. Respiratory
    • Asthma
    • Apnea
    • Emphysema
    • Hay fever
    • Shortness of breath
    • Pneumonia
    • None
  4. Cardiovascular
    • High blood pressure
    • Low blood pressure
    • High cholesterol
    • Poor circulation
    • Angina
    • Excessive bleeding
    • None
  5. Gastrointestinal
    • Anorexia / bulimia
    • Ulcer
    • Food sensitivities
    • Heartburn
    • Constipation
    • Diarrhea
    • None
  6. Genitourinary
    • Kidney stones
    • Infertility
    • Bedwetting
    • Prostate issues
    • Erectile dysfunction
    • PMS symptoms
    • None
  7. Integumentary
    • Skin cancer
    • Psoriasis
    • Eczema
    • Acne
    • Hair Loss
    • Rash
    • None
  8. Neurological
    • Blurred vision
    • Ringing in ears
    • Hearing loss
    • Chronic ear infection
    • Loss of smell
    • Loss of taste
    • None
  9. Endocrine
    • Thyroid issues
    • Immune disorders
    • Hypoglycemia
    • Frequent infection
    • Swollen glands
    • Low energy
    • None
Mother's Family History (if living)
  1. Age
  2. State of Health
  3. Illnesses
  4. If other illness, what was it?
  5. Age at Death
  6. Cause of Death
Father's Family History (if living)
  1. Age
  2. State of Health
  3. Illness
  4. If other illness, what was it?
  5. Age at Death
  6. Cause of Death
Social History
  1. Alcohol Use
  2. Coffee Use
  3. Tobacco Use
  4. Exercise
  5. Pain relievers
  6. Soft Drinks
  7. Water intake
Work History
  1. Occupation
  2. Job Requirements (lifting)
  3. Have you missed work because of this accident?
  4. If you have missed work because of this accident, by how many days?
  5. Who took you off work?
  6. If other, who took you off of work?
  7. Do you continue to work despite the pain?
  8. Did you lose your job as a result of this accident?
  9. Are you working light or restricted duty?
  10. Dominant Hand
Past Medical History
  1. Illness
    • None
    • AIDS
    • Alcoholism
    • Allergies
    • Arteriosclerosis
    • Cancer
    • Chicken Pox
    • Diabetes
    • Epilepsy
    • Glaucoma
    • Goiter
    • Gout
    • Heart disease
    • Hepatitis
    • HIV Positive
    • Malaria
    • Measles
    • Multiple Sclerosis
    • Mumps
    • Scarlet fever
    • Sexually transmitted disease
    • Polio
    • Rheumatic fever
    • Stroke
    • Tuberculosis
    • Typhoid fever
    • Ulcer
  2. Are there any other illnesses to mention?
Surgeries
  1. Any surgeries PRIOR to injury?
    • None
    • Appendix removal
    • Bypass surgery
    • Cancer related
    • Cosmetic surgery
    • Eye surgery
    • Hysterectomy
    • Pacemaker
    • Tonsillectomy
    • Vasectomy
    • Laparoscopy
  2. Elective surgeries?
  3. Other surgeries?
Medications & Allergies
  1. Please list below all prescription, over-the-counter or natural supplements you are taking
  2. Are you allergic to any medications?
  3. If yes, please list
Functional Rating Index
  1. In order to properly assess your condition, we must understand how much your neck and/or back problems have affected your ability to manage everyday activities. For each item below, please select each item which most closely describes your condition right now.
  2. Pain Intensity
  3. Sleeping
  4. Personal Care (washing, dressing, etc.)
  5. Travel (driving, etc.)
  6. Working
  7. Recreation
  8. Frequency of Pain
  9. Lifting
  10. Walking
  11. Standing
Information Not Provided
  1. Have you read the statement below?
  2. Any information that is not provided while filling out this form will need to be reviewed at the clinic on your first visit. By providing this information at this time, your initial appointment intake process will not be so lengthy. Your doctor will need a health history to complete the initial exam.
Additional Items
  1. Additional forms will need to be signed when you arrive at the clinic on your first visit. Please bring a photo ID and any previous care information related to your accident if applicable. Thank you!
  2. I will remember to...
  3. I will also bring...
  4. I understand that I will need to...