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Welcome to Central Baldwin Chiropractic Center……. Name: ____________________________________________________ Date: ______________ Last

First

Middle

Address:______________________________________________________________________________ Street

City

State

Zip

Telephone: _______________________________________Social Security #: ______________________ Home

Cell

How would you like to receive your appointment reminders (circle one)? TEXT EMAIL TELEPHONE Email Address: ________________________________________________________________________ Date of Birth: _________________ Age: ____

Sex: MALE / FEMALE

Marital Status: M D W

Employer: _____________________________________ Occupation: ____________________________ Spouse Name: ___________________________________ Telephone: ___________________________ Whom may we thank for referring you to our office?_________________________________________ Describe your pain (circle all that apply): Sharp Dull Diffuse Achy Numb Tingly Sharp with motion Stabbing with motion Electric-like with motion

Burning

Shooting Stiff Shooting with motion Other: ___________________________

Indicate on the drawing below where you have pain/symptoms How often do you experience your symptoms?  Constantly (76-100% of the time)  Frequently (51-75% of the time)  Occasionally (26-50% of the time)  Intermittently (1-25% of the time) How are your symptoms changing with time?  Getting better  Staying the same  Getting worse

0

Using a scale of 0-10 (10 being the worst), how would you rate your problem? 1 2 3 4 5 6 7 8 9 10

How much has the problem interfered with your work (circle one)? Not at all A little bit Moderately Quite a bit Extremely How much has the problem interfered with your social activities (circle one)? Not at all A little bit Moderately Quite a bit Extremely Page 1 of 3 Please continue on the back of this page.


Who else have you seen for your problem? Chiropractor Neurologist ER Physician Orthopedist Massage Therapist Physical Therapist

Primary Care Physician Other: ________________ No one

How long have you had this problem? ______________________________ How do you think this problem began? _____________________________ Do you consider this problem severe? YES

YES, AT TIMES

NO

What aggravates your problem? _________________________________________________________ What alleviates your problem? ___________________________________________________________ What concerns you most about this problem?_______________________________________________ HEIGHT _________________ WEIGHT ________________ Rate your overall health:

EXCELLENT

What type of exercise do you do?

VERY GOOD

STRENUOUS

GOOD

MODERATE

FAIR LIGHT

POOR NONE

Indicate if you have any immediate family members with any of the following: Rheumatoid Arthritis Diabetes Lupus Heart Problems Cancer ALS Please check “PAST” and/or “PRESENT” if you suffer or have suffered from the following condition(s): PAST PRESENT PAST PRESENT PAST PRESENT   Headaches   High Blood Pressure   Diabetes   Neck Pain   Heat Attack   Excessive Thirst   Upper Back Pain   Chest Pains   Frequent Urination   Mid Back Pain   Stroke   Smoking/Tobacco   Low Back Pain   Angina   Drug/Alcohol Dependence   Shoulder Pain   Kidney Stones   Allergies   Upper Arm Pain   Kidney Disorder   Depression   Wrist Pain   Bladder Infection   Systemic Lupus   Hand Pain   Painful Urination   Epilepsy   Hip Pain   Loss of Bladder Control   Dermatitis/Eczema/Rash   Upper Leg Pain   Prostate Problems   HIV / AIDS   Knee Pain   Abnormal weight Gain/Loss   Ankle / Foot Pain   Loss of Appetite FOR FEMALES ONLY   Jaw Pain   Abdominal Pain   Birth Control Pills   Joint Pain/Stiffness   Ulcer   Hormonal Replacement   Arthritis   Hepatitis   Pregnancy   Rheumatoid Arthritis   Liver/Gall Bladder Disorder   Cancer   General Fatigue   Tumor   Loss of Muscular Coordination   Asthma   Visual Disturbances   Chronic Sinusitis   Dizziness   Other: ___________ Page 2 of 3 Please continue on the next page.


List all prescription and over-the-counter medication you are currently taking: ________________________________________

_______________________________________

________________________________________

_______________________________________

List all supplements you are currently taking: ________________________________________

_______________________________________

________________________________________

_______________________________________

Have you ever been hospitalized (circle one)? YES NO If yes, why? ___________________________________________________________________________ List all surgical procedures you have had: ________________________________________

_______________________________________

________________________________________

_______________________________________

What activities do you do at home / work (circle all that apply)? SIT Most of the day Half the day A little of the day

STAND Most of the day Half the day A little of the day

COMPUTER WORK Most of the day Half the day A little of the day

ON THE PHONE Most of the day Half the day A little of the day

What activities do you do outside of work? ________________________________________

_______________________________________

________________________________________

_______________________________________

Have you ever been treated by a Chiropractor (circle one)? YES NO If yes, how long ago? _________________ Results (circle one): GREAT GOOD FAIR MIXED POOR Have you had significant past trauma (circle one)?

YES

NO

Anything else pertinent to your visit today? ________________________________________________ I affirm that the information I have given is correct to the best of my knowledge, and that it is my responsibility to inform this office of any changes in my medical status. __________________________________________________________ Signature

___________________ Date

The power that made the body, can heal the body ~ B.J. Palmer

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New Patient Forms  

Central Baldwin Chiropractic Center - New Patient Forms 2013

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