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First Name *

Last Name *

Email Address *

Date of Birth *


Male Female


Home Phone

Cell Phone

Work Phone


Family Doctor

How did you find us

Friend/Family Member Insurance Provider Directory Website Location Other (please describe)

Additional info (reference name, description, etc)

Payment for Services will be

Self Pay Health Insurance Auto Accident Workers Compensation

Are you or might you be pregnant?

No Yes

Date of last menstrual period

What are your present complaints?

When did they start?

What happened to cause these symptoms?

Where are you currently experiencing pain or other symptoms?

Lower Back Neck Other

What is your pain level?

0 1 2 3 4 5 6 7 8 9 10

Symptoms are worse in

Morning Afternoon Night Constant Come and Go

Have you ever had this before?

No Yes

If so, when?

Name, and location of doctors previously seen for present condition(s)?

Please mark where you have pain

What activities aggravate your condition?

What activities relieve your condition?

Please mark any additional symptoms you may be experiencing?

Blurred vision
Cold Hands
Upset Stomach
Facial Flushing
Buzzing in ears
Cold Sweats
Cold Feet
Light bothers eyes
Loss of balance
Loss of smell
Loss of taste
Muscle Jerking
Numbness in fingers
Numbness in toes
Ringing in ears
Shortness of breath
Stiff Neck
Pins and needles in arms
Pins and needles in legs
Concentration loss / Confusion
Depression or weeping spells
Head seems too heavy
Low resistance to colds

Do you have any allergies?

No Yes

If so, what kind?

Are you taking any medications?

No Yes

If so, what kind?

Have you been treated by a physician for any health condition in the last year?

No Yes

If so, describe condition

Date of last physical examination?

Surgical History

Surgery #1

Surgery #1 Date

Surgery #2

Surgery #2 Date

Surgery #3

Surgery #3 Date

Have you ever had a metal implant?

No Yes

List accidents you have been involved in

Accident #1 Type

Job Auto Other

Accident #1 Description

Accident #1 Date

Accident #2 Type

Job Auto Other

Accident #2 Description

Accident #2 Date

Please indicate which PAST or PRESENT conditions have been experienced prior to present complaint by marking appropriate boxes.


Self Mother Father


Self Mother Father


Self Mother Father


Self Mother Father

Back Pain

Self Mother Father

Bladder Trouble

Self Mother Father

Bone Fracture

Self Mother Father


Self Mother Father

Chest Pain

Self Mother Father


Self Mother Father


Self Mother Father


Self Mother Father


Self Mother Father

Dislocated Joints

Self Mother Father

Other Comments

Patient Consent

Patient Name *

Digital Signature *

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