Natural Wellness Chiropractic New Patient Intake Form
Title: (Circle one)
 Mr.
 Mrs.
Ms.
 Miss
 Dr.
 Other _______
First Name ___________________ Middle Initial ____ Last Name __________________________
Address ___________________________________________________________________________
City _______________________________ State ___________________ Zip Code ______________
Send/Leave Messages on: (Circle one)
Voicemail
E-mail
Text
Don’t leave messages
Contact Phone (_____) ________-___________
Email ___________________________________
Date of Birth ______/______/_______
Sex:
 Male
 Female
Marital Status:  Single  Married  Other
Emergency Contact_________________________________________________________________
Contact Name ____________________________ Relationship to Patient ___________________
Contact Phone (_____) _______-________
How did you hear about our office? ___________________________________________________
Medical Conditions: (Check all that apply to you)
 Arthritis
 Cancer
 Hypertension
 Psychiatric Illness
 Other ______________
 Fibromyalgia
 Diabetes
 Skin Disorder
 Asthma
 Heart Disease
 Stroke
 Osteoporosis
Surgeries: (Check all that apply to you)
 Appendectomy
 Cardiovascular procedure
 Joint Replacement
 Prostate
 Brain
 Shoulder
 Carpal Tunnel
 Gastro-intestinal
Breast Augmentation
Other ______________
Cervical spine
 Lumbar spine
 Thoracic spine
 Uro-genital
 Hysterectomy
 Gall Bladder
 Knee
 Hernia
Allergies: (Circle all that apply to you)
 Mold
 Seasonal
 Chemical ___________
 Sulfites
 Milk or Lactose
 Wheat/Glutens
 Animal
 Other _________
Social History: (Circle all that apply to you)
Caffeine use:
 occasional
 often
Drink Alcohol:  occasional
 often
 never
 never
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Exercise:
 occasional
Drink Water:
 <64 oz/day
Cigarettes:
<1 pack/day
Sleep:
<8 hours/night
Other ________________
 often
>64 oz/day
 >1 pack/day
 >=8 hours/night
 never
 never
 never
 Insomnia
Family History: (Circle all that apply)
Arthritis:
 Parent
 Sibling
Cancer:
 Parent
 Sibling
Diabetes:
 Parent
 Sibling
Heart Disease  Parent
 Sibling
Hypertension  Parent
 Sibling
Stroke
 Parent
 Sibling
Thyroid
 Parent
 Sibling
Other _________________
Occupational Activities: (Circle one that best describes your job description)
 Part-time work
 Business Owner
 Clerical/Secretary
 Stay at home mom
 Daycare/Childcare
 Construction
 Food Service Industry
 Medium Manual Labor
 Manufacturing
 Heavy Manual Labor
 Light Manual Labor
 Executive/Legal
 Other ________________
 Computer User
 Health Care
 Home Services
 Housekeeper
Doctor’s Signature _________________________________________________ Date______________
Patient’s Signature __________________________________________________Date______________
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Review of Systems – (Check box if you have had trouble with any of the following)
No
Cardiovascular
Past
No
Respiratory
Present
Past
Poor Circulation
Hypertension
Aortic Aneurism
Heart Disease
Heart Attack
Chest Pain
High Cholesterol
Pace Maker
Jaw Pain
Irregular Heartbeat
Swelling of legs
Asthma
Tuberculosis
Short Breath
Emphysema
Cold/Flu
Cough
Wheezing
Past
Present
Past
Present
Past
Present
Past
Present
Hives
Immune Disorder
HIV/AIDS
Allergy Shots
Cortisone Use
No
Ear, Nose and Throat
No
Eyes
No
Genitourinary
Past
Past
Present
Past
Present
Glaucoma
Double Vision
Blurred Vision
Present
Kidney Disease
Burning Urination
Frequent Urination
Blood in Urine
Kidney Stones
Lower Side Pain
No
Psychiatric
Depression
Anxiety
Stress
No
Neurologic
Past
Present
No
Past
Present
Past
Present
Thyroid
Diabetes
Hair Loss
Menopausal
PMS
Stroke
Seizures
Head Injury
Brain Aneurysm
Numbness
Severe Headaches
Pinched Nerves
Parkinson’s
Carpal Tunnel
Vertigo
No
Past
Present
No
Gall Bladder Problems
Bowel Problems
Constipation
Liver Problems
Ulcers
Diarrhea
Nausea/Vomiting
Bloody Stools
Poor Appetite
No
Hematologic
Constitutional
Difficulty Swallowing
Dizziness
Hearing Loss
Sore Throat
Nosebleeds
Bleeding Gums
Sinus Infections
Gastrointestinal
Endocrine
Weight Loss/Gain
Low Energy Level
Difficulty Sleeping
No
Allergic/Immunologic
Present
Hepatitis
Blood Clots
Cancer
Bruising
Bleeding
Fever, Chills
Sweating
Varicose Vein
No
Musculoskeletal
Gout
Arthritis
Joint Stiffness
Muscle Weakness
Osteoporosis
Broken Bones
Joints Replaced
Neck Pain
Low Back Pain
Upper Back Pain
Please list all current medications being taken ________________________________________________
_____________________________________________________________________________________
How are your symptoms changing? Getting better
Not changing  Getting worse 
Are You Pregnant? (Circle) Yes
No
Patient’s Signature ________________________________________ Date : ______________
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Patient Name_____________________________________________Date_____________________
By Using the key below, indicate on the body diagram where you are experiencing the following
symptoms:
N=Numbness
B=Burning
S=Sharp
T=Tingling
A=Dull Ache
Average Pain Intensity:
Last 24 hours: no pain 0 1 2 3 4 5 6 7 8 9 10 worst pain
Past week:
no pain 0 1 2 3 4 5 6 7 8 9 10 worst pain
Does anything improve your pain?
Yes No If Yes, please list:
When did your symptoms begin?
________________________________________________
Are your symptoms a result of:  Motor Vehicle Accident
Work related Accident  Other_____
How did your symptoms begin? _________________________________________________________
_____________________________________________________________________________________
How often do you experience your symptoms?
 Constantly
 Frequently
(76-100% of the day)
 Occasionally
(51-75% of the day)
(26-50% of the day)
What describes the nature of your symptoms?
 Sharp
 Ache
 Burning
 Tingling
 Numb
 Throbbing
 Intermittently
(0-25% of the day)
 Shooting
 Other ______
Doctor’s Signature ___________________________________________Date______________________
Patient’s Signature____________________________________________Date______________________
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