West Family Chiropractic
Confidential New Patient Intake Form
(Please Print)
Today’ Date_______/______/_______
(Office use only) Chart Number_______________________
Patient Information
Mr./ Mrs./ Ms. Name
Miss. / Dr./…..
Mailing Address
Birth Date
/
/
Age
/
Cell Phone
(
)
Nick Name
City
Marital status
State
Social security #
S /M /D / W
Fax
(
)
Race
Zip
Home phone
Work phone
(
(
E-mail Address
)
)
Preferred method of contact
Occupation.
Employer
Employer Address
Primary Care Physician (PCP)
PCP Address
PCP Phone
(
)
Who referred you to our office?
Family Spouse Information
Spouses Name
Number of Children
Insurance Information
Are You Insured ? Yes
 No
[ If Yes please present your insurance card(s) to the front desk ]
Subscriber (The person who the insurance is through)
Subscribers Birth Date
/
/
/
Personal, Automobile or Work Related Injury Information
*** If this a Personal, Automobile or Work Related injury please fill out additional forms at the front desk
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West Family Chiropractic
Confidential New Patient Intake Form
(Please Print)
Name:_____________________________________________
(Office use only) Chart Number________________
Health history
What is your main complaint?
How long have you had this complaint?
What do you think caused your current problem?
Have you ever had this complaint before?
Yes
 No
Have you seen other practitioners for this complaint?
Have you had chiropractic care before?
Yes
 No
(If yes please list)
Yes
 No
(If yes please list)
(If yes please list)
Please mark the areas on the picture below that correspond to the areas of the body where you feel the described
sensations. Use appropriate symbols. Mark areas of radiation. Include all affected areas.
Do not simply circle the area of involvement please
Numbness -----
Pins & needles oooooo
Burning xxxxx
Aching    
Stabbing /////
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West Family Chiropractic
Confidential New Patient Intake Form
(Please Print)
Name:_____________________________________________
(Office use only) Chart Number________________
Pain Assessment: Quadruple Visual Analogue Scale
Instructions: Please CIRCLE the number that best describes the question being asked
Note: If you have MORE than one complaint, please answer each question for each
individual complaint and indicate the score for each complaint.
For example: If you have neck & low back complaints circle the pain level for EACH of those complaints
What is your pain right now?
No Pain
|________________________________________________________|
0
1
2
3
4
5
6
7
8
9
10
Worst possible pain
What is your Typical or Average pain?
No Pain
|________________________________________________________|
0
1
2
3
4
5
6
7
8
9
10
Worst possible pain
What is your pain level at its best (How close to “0”
does your pain get at its best)?
No Pain
|________________________________________________________|
0
1
2
3
4
5
6
7
8
9
10
Worst possible pain
What is your pain at its worst (How close to “10” does
your pain get at its worst?
No Pain
|________________________________________________________|
0
1
2
3
4
5
6
7
8
9
10
Worst possible pain
****** Please continue on the next page ******
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West Family Chiropractic
Confidential New Patient Intake Form
(Please Print)
Name:_____________________________________________
(Office use only) Chart Number________________
Health history Cont…
Please list any other current health conditions
Please list any history of surgeries
Please list current medications
Any allergies to medications?
Please list current vitamins and supplements
Please list any other physicians / Practitioners that you currently see
Have you been diagnosed with Hypertension?
If yes, please describe
Have you been diagnosed with Diabetes? If yes, are you type 1 or 2? Any other comments about your diabetes?
Do you currently smoke tobacco of any kind? Y / N
Are you interested in quitting? Y / N
If NO, have you had a past history of smoking? Y / N
If yes, everyday or sometimes?
I certify that the above information is correct to the best of my knowledge.
Signature: __________________________________________
Date_____ /______/______
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