PATIENT INTAKE FORM                     Brookhaven Chiropractic Center

 

 

Today’s Date__________________

 

 

Full Legal Name____________________________________________

 

Name you prefer to be called__________________________________

 

Male___   Female___   Date of Birth ______-_____-_____ Age_____ SS#________-________-________

 

Mailing Address____________________________________________

 

City___________________________ State_______ Zip__________________

 

Home Phone______________________ Cell______________________

 

Work Phone ___________________Ext_____   Circle preferred contact number:   Home    Cell      Work

 

E-mail Address__________________________________________________

 

Occupation___________________________________________________________

 

Employer Name__________________________________

 

Employer Address ________________________ City___________ State ____ Zip______

 

Referred by____________________________________________________

 

Status: ____Minor      ____Single      ____Married      ____Widow/Widower      ____Divorced

 

Spouse’s Name______________________ Children? ___Y   __N   How Many?_______

 

Emergency Contact____________________________   Phone (____)_______________

 

 

We send appointment reminders for any future appointments via text message or e-mail the day before your appointment.  Please check your preference:

 

            _____Text message (please provide cell phone carrier:_____________________________)

 

            _____E-mail

 

 

Insurance Company________________________________________

 

Primary Insured’s Name_____________________________________ DOB:__________________

 

Insured’s Employer_________________________________   Relation to You__________________

 

 

Secondary Insurance Co.____________________________________   

 

Insured’s Name____________________________________________ DOB:_________________

 

Insured’s Employer___________________________________________

 

 

Reason for today’s visit: ___Emergency   ___New Injury   ___Old Injury   ___Chronic Pain   ___Wellness

 

Where do you hurt? _________________________________________________________

 

Circle the level of your pain:    (mild)   1   2   3   4   5   6   7   8   9   10   (intense)

 

If injury, did it occur during:  ___Work    ___Auto Accident    ___Sports/Play     ___Routine/Home Activity

 

When did injury occur? ___________   Where did injury occur?_____________________________­____

 

Is condition getting worse?  Yes____   No____   Constant____   Come and Go____

 

 

 

 

 

 

 

Has something like this happened in the past?  Yes____   No____

 

Explain:______________________________________________________________________________________________________________________________________________________________

 

________________________________________________________________________________

 

 

Other physicians seen for this:  (M.D.___   D.C.___)     How long ago? ____________________________

 

Have you ever been treated by a Chiropractor (D.C.)?  Yes___   If so, what year?__________     No___

 

Where? __________________________________________________________________________

 

 

Please list all current medications and supplements you are taking:_____________________________

 

________________________________________________________________________________

 

________________________________________________________________________________

 

 

Have you ever had or currently have the following?  Check those that apply:

 

 

___Attack/Stroke             ___Sleep Difficulties/Insomnia                ___Fainting/Epilepsy/Seizure

 

___Artificial Valves                                ___Heart Surgery/Pacemaker                 ___Chemotherapy/Radiation

 

___Shingles                                          ___Cancer                                       ___Frequent Neck Pain

 

___High/Low Blood Pressure                  ___Alcohol/Drug Abuse                          ___Chronic Sinus Infection

 

___Fibromyalgia                                    ___Anxiety/Depression                          ___Low Back Problems

 

___Chronic Fatigue Syndrome                ___Kidney Problems                              ___Glaucoma

 

___Thyroid Disorder                               ___Irritable Bowel/IBS                            ___Severe/Frequent Headaches

 

___Acid Reflux                                      ___Cold Hands/Feet                              ___Asthma/Emphysema

 

___Ulcers/Colitis                                   ___Unexplained Weight Gain                  ___Implants/Transplants/Artificial Joints

 

___Difficulty Breathing                           ___Restless Leg Syndrome                    ___Diabetes

 

                                                                                                           

 

Your height: ____________________

 

Do you currently take prescription medications for bone density?         Yes     No

 

Do you currently take medications for diabetes?                                     Yes     No

 

Do you exercise on a regular to semi-regular basis?                              Yes     No

 

What is your physical activity level in an average day?   Not Active    Moderately Active     Very Active           

 

How healthy do you consider yourself to be?   Not Healthy     Moderately Healthy     Very Healthy

 

 

List any surgeries or other diagnoses not listed above:_____________________________________

 

_______________________________________________________________________________

 

_______________________________________________________________________________

 

_______________________________________________________________________________

 

Allergies:________________________________________________________________________

 

Do you smoke? Yes___  No___    How many?____ How long?____  Quit?____ How long ago?____

 

Birth Control? Yes___ No___         Pregnant? Yes___ No___               Nursing? Yes___ No___

 

 

Signature:__________________________________________   Date:________________________