New Patient Intake Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Patient InformatonFirst NameLast NameAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code past had of Is this condition associated with a child developmental concern or condition?YesNoPatient DemographicsDate of Birth *Gender *Marital StatusSingleMarriedDivorcedSeparatedWidowedOtherSpouse's NameNumber of ChildrenHeight and WeightHeight (feet) Selected Value: 3 Height (inches) Selected Value: 0 Weight (lbs) Selected Value: 0 Contact InformationPhone *Phone Type *MobileHomeOtherEmail *EmailConfirm EmailEmergency ContactName *PhoneRelationInsurance InformationDo you have insurance?NoYesInsurance NamePhoneInsurance AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeID/Policy NumberGroup NumberInsured's NameInsured's Date of BirthReferral InformationReferring PhysicianReferring PatientAre you working with an attorney?NoYesHow did you hear about us?Word of MouthInternet SearchSocial MediaOnline ReviewLocal ListingAdvertisementCommunity EventEmail MarketingInsurance NetworkHealthcare Provider ReferralThe Reason for Your VisitWhat is the main reason for your visit?Select a ReasonAuto accident (job related)Auto accident (personal)Cycle AccidentGeneral WellnessHome InjuryInjured by a vehicle as a pedestrianPainSlip and fall (away from home)Sports InjuryOtherOther reason for your visit?Date of Scheduled AppointmentDateTimeApproximate date this condition began?What caused this condition?Select a CauseUnknownAfter a fallAfter a long diveAfter a long flightAfter a poor night's sleepAfter a slipAfter lifting an objectAfter reaching or overarchingAfter performing household choresAfter performing yardworkAfter sitting in one place for a too longAssociated with prolonged or chronic illnessOtherOther cause?Auto Accident DetailsWhere in the vehicle were you at the time of the accident?Select OneDriverFront CenterFront PassengerBack Seat LeftBack Seat CenterBack Seat RightBack Seat Left (Car Seat)Back Seat Center (Car Seat)Back Seat Right (Car Seat)Back Seat Left (Booster Seat)Back Seat Right (Booster Seat)OtherIn what direction were you looking at the time of impact?Select OneDownOver Left ShoulderOver Right ShoulderStraight AheadTo the LeftTo the RightNot SureAccident DetailsWere you wearing a seatbelt?Did the airbag deploy?Did you come in contact with anything at the time of the collision?Did you receive an injury to the head?Did you lose consciousness?Did your head hit the headrest?Cycle Accident DetailsWere you the Driver or Passenger of the cycle?Select OneDriverPassengerWhat type of cycle were you riding?Select OneMotorcycleScooterMopedBicycleOtherIn what direction were you looking at the time of impact?Select OneDownOver Left ShoulderOver Right ShoulderStraight AheadTo the LeftTo the RightNot SureWhat type of protective gear were you wearing?Choose all that apply.Bicycle HelmetMotorcycle Helmet - Full FaceMotorcycle Helmet - Open FaceMotorcycle Helmet - Half HelmetLeathersGlovesBootsProtective EyewearOtherPersonal Impact DetailsI came in contact with an object when the collision occurred.I received a head injury.I lost consciousness.What part of your vehicle or cycle was impacted?Choose all that apply.Front RightFront LeftFront Head-onRear EndRear End Right SideRear End Left SideRight Side (Driver)Left Side (Driver)UnknownNoneIn what direction was your vehicle or cycle moving?Select OneBacking upMoving forwardStoppedTurning LeftTurning RightNot MovingNot SureWhat was the estimated speed?Select OneLess than 15 MPH15 to 25 MPH25 to 40 MPH40 to 70 MPHOver 70 MPHWhat was the damage to your vehicle or cycle?Select OneVehicle TotaledHeavily DamagedModerately DamagedSlightly DamagedNo DamageNot SureIn what direction was the other vehicle or cycle moving? Select OneBacking upMoving forwardStoppedTurning LeftTurning RightNot MovingNot sureWhat was the estimated speed of the other vehicle or cycle?Select OneLess than 15 MPH15 to 25 MPH25 to 40 MPH40 to 70 MPHOver 70 MPHWhat was the damage to the other vehicle or cycle?Select OneVehicle TotaledHeavily DamagedModerately DamagedSlightly DamagedNo DamageNot SureAccident Scene LogisticsYour vehicle or cycle was towed.The police arrived at the scene.The police recorded an accident report.Emergency Medical Services (EMS) arrived on the scene.Please estimate the speed of the vehicle.Select OneLess than 15 MPH15 to 25 MPH25 to 40 MPH40 to 70 MPHOver 70 MPHWhat were you doing when the accident occurred?Select OneCrossing the street.JoggingRiding a non-motorized scooter.Riding a skateboard.RollerbladingStandingWaiting for public transportation.Walking in a crosswalk.WalkingOtherWhich direction were you facing at the moment of impact?Select OneDownOver my left shoulder.Over my right shoulder.Straight ahead.To my left.To my right.Not sure.Accident Scene DetailsYou received a head injury.You lost consciousness.The police arrived at the scene.The police recorded an accident report.Emergency Medical Services (EMS) arrived on the scene.Please check all that apply at the scene of the accident.How did you leave the scene of the accident?Select OneTransported to the hospital.Denied transport by Emergency Services.Driven to the hospital by Emergency Services.Driven to the Emergency Room by Emergency Services.Drove home.Arranged for a ride.Continued to my destination.Where was the discomfort felt immediately after the accident?Choose all that apply.AbdomenBackChestFaceHeadNeckRight shoulder, elbow, arm or handLeft shoulder, elbow, arm or handRight hip, thigh, knee, leg or footLeft hip, thigh, knee, leg or footAreas of Concern and DiscomfortFront of BodySelect AreaForeheadTemplesJawFront of NeckThroatLeft ShoulderLeft Upper ArmLeft ElbowLeft ForearmLeft WristLeft HandRight ShoulderRight Upper ArmRight ElbowRight ForearmRight WristRight HandUpper ChestLower ChestUpper AbdomenLower AbdomenLeft HipLeft ThighLeft KneeLeft ShinLeft AnkleLeft FootRight HipRight ThighRight KneeRight ShinRight AnkleRight FootBack of BodySelect AreaBack of HeadBack of NeckLeft Shoulder BladeRight Shoulder BladeUpper BackMid BackLower BackLeft HipLeft ButtockLeft ThighLeft KneeLeft CalfLeft AnkleLeft HeelRight HipRight ButtockRight ThighRight KneeRight CalfRight AnkleRight HeelWhat term(s) describes your discomfort best?Choose all that apply.AchingBurningDeepDullIntolerableSharpShootingStabbing/ThrobbingStiffnessTightnessTinglingRate the severity of your discomfort at its worst. Severity: 1 On a scale from 1 to 10, where 1 is the least severe and 10 is the most severe.How often do you feel this discomfort?Select OneConstantFrequentOff and onRecurringHow has this complaint changed since the onset?Select OneImprovedStayed the sameGotten worseWhat activity is most significantly affected by this discomfort?Select the Most SignificantEmploymentHomemakingLiftingPersonal care (bathing, dressing, etc.)SittingSleepingSocial LifeStandingTraveling and/or DrivingWalkingOtherWhat treatment, if any, have you received since the injury?Choose all that apply.NoneChiropractic careMassageMedical injection treatmentSurgical treatmentOver-the-counter medicationsPrescribed medicationsNatural or holistic treatmentAcupuncturePhysical therapyOtherWhat aggravates this condition?Choose all that apply.Almost any movementAthletic activity and/or exerciseBendingCarrying or liftingChanging positionsCoughing and/or sneezingDaily child or pet careGetting out of bed, chair or carHousehold chores (cleaning, cooking, etc.)Looking over shoulderLying down, getting and staying asleepPulling, pushing or reachingRaising arm(s) above shoulder(s)Self care (dressing, bathing, etc.)Sitting in car or chairSquatting or bendingStandingStressWalking or runningWorking at a desk/computerYardworkUnknownOtherWhat improves this condition or gives you relief?Choose all that apply.NothingChiropractic adjustmentPrescription medicationsCold packsRe-directs attentionExerciseRestHeat packsStretchingMassageWorkOver-the-counter medicationsPhysical therapyOtherHave other health care provider(s) performed tests related to this condition?NoNoYesHave you ever had any previous episodes of this condition?NoNoYesWellness InformationResearch shows that your spine should be checked regularly. How many times have you visited a Chiropractor in your lifetime?Select One1 to 1011 to 2525 or moreNeverWhen was your last Chiropractic adjustment?Select OneWithin the past month.Withing the past 6 months.Within the past 12 months.Over 12 months ago.Never been adjusted.Wellness QuestionsDo you practice good nutritional habits?Do you think your weight is suitable for your height?Do you use any nutritional supplements, such as vitamins, minerals, or herbs?Do you believe you have healthy and positive attitudes?Do you think you are in good overall health, including vision, dental, and hearing?If the answer is yes to any of the questions above, then please check the associated box.Stress can cause or accelerate spinal damage. On a scale from 1 (Low) to 10 (High), how would you rate your stress level over the past 90 days? Selected Value: 1 On a scale from 1 (Extremely Poor) to 10 (Restful), with 5 being Interrupted Sleep, how well do you sleep throughout the night? Selected Value: 0 Describe your overall mood on a daily basis?Select OneGenerally HappyContentUp and DownFrequently AgitatedDepressedHow often do you exercise?Select OneEveryday3 or more times a week.Once a week.RarelyNeverDo you have an additional condition?NoNoYesSubmit
