NEW PATIENT QUESTIONAIRE
                                GENERAL INFORMATION:
Name ____________________________________      Male Female   Date ___________
(circle one)
Address __________________________________________ Home phone____________
City __________________ State _____ Zip code _________ Cell phone _____________
Date of Birth _________Social Security# ________________ Work phone ___________
Employer _________________________ Occupation ____________________________
Address ______________________ City ___________ State _______ Zip code _______
DESCRIPTION OF INJURY:
1. What is the date of your injury?  ___________________________________________
2. Is your injury the result of an: auto accident work injury other
(circle one)
If other, please explain._____________________________________________________
________________________________________________________________________
________________________________________________________________________
3. Have you seen a chiropractor, medical doctor or physical therapist outside of this
office for you injury? _________ If yes, whom did you see?    ______________________
4. Using the diagram below, please mark the areas of your pain.
5. Describe the character of your symptoms: (circle ones that apply)
burning tingling numbness dull stabbing shooting radiating
6. Since your symptoms began have they: improved worsened stayed the same?
(circle one)
7. Are your symptoms: constant intermittent?
(circle one)
8. List anything that you have tried to relieve you symptoms, please explain.
________________________________________________________________________
________________________________________________________________________
9. What aggravates your symptoms?  __________________________________________
________________________________________________________________________
10. Is your sleep disturbed by these symptoms? Yes No
(circle one)
11. Are you restricted/limited in any work, home, or recreational activities because of
your injury? Yes No If yes, please explain. _____________________________________
_______________________________________________________________________
_______________________________________________________________________
Medical/Social History
1. Have you or any of your family members suffered from any of the following
conditions?
(Answer Y or N)
ALLERGIES _________________________ EPILEPSY ________________________
ALCOHOL DEPENDENCE ____________ FATIGUE _________________________
ANEIMA ___________________________ HEART ATTACK/DISEASE___________
ARTERIOSCLEROSIS ________________ HIGH BLOOD PRESSURE____________
ARTHRITIS ________________________ HIV INFECTION  ____________________
BACK SURGERY ____________________ KIDNEY DISEASE _________________
BROKEN BONES ____________________ LOW BLOOD PRESSURE _____________
CANCER ___________________________ MIGRAINES ________________________
DEPRESSION _______________________ MOTION SICKNESS _________________
DIABETES __________________________ MULTIPLE SCLEROSIS ______________
DIZZINESS/FAINTING _______________ POLIO _____________________________
DOUBLE OR BLURRED VISION _______ RHEUMATIC FEVER ________________
DRUG DEPENDENCE ________________ STROKE ___________________________
EAR INFECTIONS ___________________ TMJ _______________________________
Please explain, if necessary. _________________________________________________
________________________________________________________________________
2. If you have any condition/disease not listed above, please explain. ________________
________________________________________________________________________
________________________________________________________________________
3. Do you smoke? Yes No If yes, how often?_______________________
(circle one)
4. Do you drink alcohol? Yes No If yes, how often? ______________________
(circle one)
5. Do you drink caffeinated beverages? Yes No If yes, how often?___________
(circle one)
6. Please list all medications that you are presently taking. ________________________
________________________________________________________________________
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WOMEN ONLY:
1. Are you pregnant or think you may be pregnant ? ____________________
2. Please list the date of your last menstrual period. ____________________
3. Do you or have you suffered from any menstrual disorders? ____________________
If yes, please explain: ___________________________________________________
________________________________________________________________________
________________________________________________________________________
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I CERTIFY THAT I HAVE READ AND UNDERSTAND THE ABOVE
INFORMATION. THE ABOVE QUESTIONS HAVE BEEN ACCURATELY
ANSWERED TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT
PROVIDING INCORRECT INFORMATION CAN BE DANGEROUS TO MY
HEALTH.
________________________ _______________________________________
DATE PATIENTíS SIGNATURE