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About
Meet Our Doctors
Services
Auto Accidents
New Patients
Medical
Chiropractic
Blog
Reviews
Contact
Call Us
(850) 386-8282
Chiro New Patient Intake Form
New Patient History
Name
First
Last
Current Date
MM slash DD slash YYYY
Last 4 of Social Security Number
Date Of Birth
MM slash DD slash YYYY
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Primary Phone Number
Cell Phone Carrier
Email
Primary Care Physician
Have you ever been to a chiropractor before? (Yes or No)
If Yes, where?
For what condition?
How did you respond to treatment?
How did you hear about our clinic?
What type of insurance do you have
CHP
Blue Cross
Aetna
Other
Other
Type of Pain
Select All That Apple
Sharp/Stabbing
Burning
Ache
Dull
Numb/Tingling
Other
Other
Do you have a personal history of cancer?
Yes
No
Have you had any unexplained weight loss?
Yes
No
Recent trouble starting or stopping urination?
Yes
No
Recent trouble with bowel movements?
Yes
No
Numbness in the groin region?
Yes
No
Recent muscle weakness in the legs?
Yes
No
History of significant trauma?
Yes
No
Do you have osteoporosis?
Yes
No
History of prolonged use of corticosteroids?
Yes
No
Do you have a connective tissue disorder?
Yes
No
Current or recent infection?
Yes
No
History of immunosuppression medication &/or condition?
Yes
No
Do you have hypertension?
Yes
No
Do you smoke?
Yes
No
Past History
PREVIOUS INJURIES (Please give dates, describe injury and care received)
Auto Related Injuries
Work Related Injuries
Personal Related Injuries
List any Surgeries
LIST ALL MEDICATIONS/VITAMINS:
CURRENT MEDICAL CONDITIONS: ie. (diabetes, high blood pressure, high cholesterol, etc)
Please use the numbers below when answering. If you have never had the condition, please leave blank.
1.Current 2.Related to auto accident
General Symptoms
Headache
Please enter a number from
1
to
2
.
Fever
Please enter a number from
1
to
2
.
Chills
Please enter a number from
1
to
2
.
Night Sweats
Please enter a number from
1
to
2
.
Fainting
Please enter a number from
1
to
2
.
Dizziness
Please enter a number from
1
to
2
.
Fatigue
Please enter a number from
1
to
2
.
Nervousness
Please enter a number from
1
to
2
.
Loss of Weight
Please enter a number from
1
to
2
.
Numbness or pain in arms/legs/hands
Please enter a number from
1
to
2
.
Muscle & Joints
Weakness
Please enter a number from
1
to
2
.
Stiff Neck
Please enter a number from
1
to
2
.
Backache
Please enter a number from
1
to
2
.
Swollen Joins
Please enter a number from
1
to
2
.
Gastro-Intestinal
Nausea
Please enter a number from
1
to
2
.
Vomiting
Please enter a number from
1
to
2
.
Vomiting Blood
Please enter a number from
1
to
2
.
Constipation
Please enter a number from
1
to
2
.
Diarrhea
Please enter a number from
1
to
2
.
Cardiovascular
High Blood Pressue
Please enter a number from
1
to
2
.
Low Blood Pressue
Please enter a number from
1
to
2
.
Heart Trouble
Please enter a number from
1
to
2
.
Swelling Ankles
Please enter a number from
1
to
2
.
Poor Circulation
Please enter a number from
1
to
2
.
Varicose Veins
Please enter a number from
1
to
2
.
Strokes
Please enter a number from
1
to
2
.
Eye/Ear/Nose/Throat
Poor Vision
Please enter a number from
1
to
2
.
Pain In Eyes
Please enter a number from
1
to
2
.
Ear ache
Please enter a number from
1
to
2
.
Ear Noises
Please enter a number from
1
to
2
.
Nose Bleeds
Please enter a number from
1
to
2
.
Skin Allergies
Bruising Easily
Please enter a number from
1
to
2
.
Sensitive Skin
Please enter a number from
1
to
2
.
Hives or Allergies
Please enter a number from
1
to
2
.
Eczema
Please enter a number from
1
to
2
.
Respiratory
Chronic Cough
Please enter a number from
1
to
2
.
Spitting Blood
Please enter a number from
1
to
2
.
Chest Pain
Please enter a number from
1
to
2
.
Difficult Breathing
Please enter a number from
1
to
2
.
Genito-Urinary
Painful Uriniation
Please enter a number from
1
to
2
.
Blood in Urine
Please enter a number from
1
to
2
.
Kidney Infection
Please enter a number from
1
to
2
.
Inability to control urine
Please enter a number from
1
to
2
.
Other conditions not listed above:
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health.
Signature of patient (or parent of minor)
First
Last
Current Date
MM slash DD slash YYYY
Schedule A Consultation
(850) 386-8282
Book an Appointment
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Meet Our Doctors
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Auto Accidents
New Patients
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Chiropractic
Blog
Reviews
Contact
850.386.8282
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Name
Email
Phone Number
Reason For Inquiry
Interested in Chiropractic
Interested in Hormone Therapy
Interested in Weight Loss
Interested in Massage
Interested in Dry Needling
Interested in Medical Aesthetics
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