Brookfield Family Chiropractic
NEW
PATIENT INFORMATION
Welcome to our office! Please
complete all questions below.
Name: (Full)
____________________________Nickname: _______________________
Address:
_______________________________ City/State: _____________ Zip: ______
Home
Phone: ___________________________ Cell Phone: _______________________
Social
Security Number: ___________________ Gender: Male
Female
Birth Date: ____/____/_______
Age: _____
Marital Status: Single
Married Widowed
Divorced Legally Separated
e-mail Address:
__________________________Can we contact you by e-mail? _______
Employer:
______________________________ Occupation: ______________________
Work
Phone: ____________________________
Do you have health Insurance?
Yes No Insurance Co: ____________________
Method of payment for first visit: Cash
Check Credit Card
Spouse’s
Name: __________________________ Spouse’s Birth Date: ____/____/_____
Spouse’s
Employer: _______________________ Spouse’s SSN: ___________________
Children’s
names and ages: _________________________________________________
Who
may we thank for referring you? _________________________________________
Have
you had previous Chiropractic Care? Yes No
If yes, Doctor’s Name: ______________________ Last Visit Date: _________________
Is your pain the result of an: Auto Accident?
Yes No Work Injury?
Yes No
Are you taking prescription
medications now? Yes No Over the counter? Yes No
List:
Please list any Vitamins,
Minerals, Herbs, or Nutritional Products that you are currently taking: _________________________________________________________________
For Women: Last Menstrual Period: ____________ Are you pregnant?
_____________
The
above information is true to the best of my knowledge.
Patient or Guardian
Signature: _______________________________Date: __________
Brookfield Family Chiropractic
NEW PATIENT HEALTH QUESTIONNAIRE
Please fill out questions below.
CURRENT HEALTH CONDITION
Main Complaint: _________________________________________________________
How long have you had it? ___________________Have you had it before?
Yes No
Rate Pain on a scale of: (1-mild to 10 severe)
1 2 3 4 5 6 7 8 9 10
Describe the Pain: Sharp Dull
Aching Throbbing Numbness/Tingling
Other: ________________________________________________
Constant
Comes & Goes How often? _________________
Does
the Pain Radiate? No Yes
Where? ________________________________
Is the pain worse in the:
Morning Afternoon Night
No Difference
Activities Painful to Perform:
Sitting Walking
Bending Lying Down
Other: ______________________________________
Does it interfere with: Work Sleep
Daily Routine Recreation _____
Other Doctors Seen for this condition: ________________________________________
Recommendations or Treatment: _____________________________________________
Additional health concerns/complaints in order of seriousness.
Rate pain on scale of 1-10
1. ____________________________________
4. _______________________________
2. ____________________________________
5. _______________________________
3. ____________________________________ 6. _______________________________
Anyone in your family with similar problems? _________ If yes, who? ______________
Past
Health History
Major Surgery/Operations:
Appendectomy
Tonsillectomy Gall Bladder Hernia
Back Surgery Broken bones Hysterectomy
Ear Tubes Child Birth
Other: ________
Major Accidents of Falls: __________________________________________________
Hospitalizations (other than above): __________________________________________
Heavy Mod Light
None
Within 2 years
Habits:
Date of Last:
Alcohol
Chiropractic Adjustment
Coffee/Tea
Spinal Examination
Pop/Soda
Physical Exam
Tobacco
Blood Test
Exercise
Chest x-ray
Sleep
Spinal X-ray
Patient Signature: _______________________________________
Date: ____________
Brookfield Family Chiropractic
207
NE Delaware Suite 22, Ankeny, IA 50021 (515) 963-9715
WHAT IS YOUR HEALTH PHILOSOPHY? (What should
you do to be healthy?)
____________________________________________________________________
____________________________________________________________________
HOW DO YOU WANT US TO HANDLE YOUR PROBLEM?
_____Temporary relief
(help the symptoms but do not fix the cause of the problem)
_____ Maximum Correction (Correct
the cause of the problem for maximum stability in the future)
WHY DID YOU COME INTO OUR
CLINIC AND WHAT ARE YOUR EXPECTATIONS OF US? ______________________________________________
_____________________________________________________________________
1 What are your favorite hobbies or activities to do now?_______________________
______________________________________________________________________
2 Are your current problems affecting these activities or
hobbies? Yes No
3
What activities are you looking forward to doing in retirement? _________________
______________________________________________________________________
4 Who would you like to be doing these with? ________________________________
On a scale of 1-10 (10 being the most, and 1 being the least).
_____ How important do you feel nutrition is to optimal health?
_____ How important
do you feel exercise is to optimal health?
_____ How many days a week do you exercise at least 30
minutes?
1 2
3 4
5 6
7
_____How committed are you to reaching your maximum health potential?
_____How
important is it for your family to be at their maximum health potential?
_____ How committed are
you to preventing illness & disease and maximizing your spinal
stability?
Are you currently wearing:
Heel Lifts Arch Supports
PLEASE FEEL FREE TO DISCUSS OUR FEES. FEES ARE PAYABLE WHEN SERVICES ARE
RECEIVED UNLESS SPECIAL ARRANGEMENTS ARE MADE IN ADVANCE.
Signature:
_______________________________________ Date: __________________
