New Patient Health History Form

New Patient Health History Form

Dr. Todd Gewant D.C.
Patient Data
Name*

First NameLast Name
Date

MonthDayYear
Phone (Home)
Phone (Cell)*
E-mail (Your email will NOT be shared with any third parties, and is used for occasional office announcements and promotions.)*
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
Referred By
Age
Birth Date

MonthDayYear
Number of Children
Occupation
Employer
Marital Status
Spouse's Name

First NameLast Name
Spouse's Occupation
Spouse's Employer
Spouse's Health Status
Emergency Contact

First NameLast Name
Contact Number
Current Complaints

Nature of InjuryAutomobileWorkOther
Please Describe
Date of Injury

MonthDayYear
Date Symptoms Appeared

MonthDayYear
Have you ever had same condition?

NoYes
If yes, when?
List other practitioners seen for this injury/condition
Have you ever been under chiropractic care?

NoYes
If yes, please describe
Insurance Information
Name of party responsible for payment

First NameLast Name
Phone
Do you have health insurance?

NoYes
Name of employer
Insurance company name
Contact Person

First NameLast Name
Phone
Claim #
Signatures
Name of the Insured

First NameLast Name
I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.
Patient's Signature
Date

MonthDayYear
Spouse's or Guardian's Signature
Date

MonthDayYear
Medical History
Have you been treated for any conditions in the last year?

NoYes
If yes, please describe
Date of last physical exam

MonthDayYear
Is there a chance that you are pregnant?

NoYes
Have you had x-rays taken?

NoYes
If yes, where?
What medications are you taking and for what conditions?
Please list dosage and amounts, etc.
What vitamins, minerals or herbs do you current take?
Please list for what condition, dosage and frequency
Have you ever:
Broken bones?

NoYes
Briefly explain
Been hospitalized?

NoYes
Briefly explain
Been in an auto accident?

NoYes
Briefly explain
Had sprains/strains?

NoYes
Briefly explain
Been struck unconscious?

NoYes
Briefly explain
Had surgery?

NoYes
Briefly explain
Family History
Family members - Present and past health conditions
Example: heart disease, cancer, diabetes, arthritis, etc.
Do you experience pain every day?

NoYes
Do your symptoms interfere with daily life?

NoYes
Does pain wake you up at night?

NoYes
Are your symptoms worse during certain times of the day?

NoYes
Do changes in weather affect your symptoms?

NoYes
Do you wear orthotics?

NoYes
Do you take vitamin supplements?

NoYes
What activities aggravate your symptoms?
Habits
Alcohol

NoYes
Coffee

NoneLightModerateHeavy
Tobacco

NoneLightModerateHeavy
Drugs

NoneLightModerateHeavy
Exercise

NoneLightModerateHeavy
Sleep

NoneLightModerateHeavy
Appetite

NoneLightModerateHeavy
Soft Drinks

NoneLightModerateHeavy
Water

NoneLightModerateHeavy
Salty Foods

NoneLightModerateHeavy
Sugary Foods

NoneLightModerateHeavy
Artificial Sweeteners

NoneLightModerateHeavy
Have you ever suffered from:

AlcoholismAllergiesAnemiaArteriosclerosisArthritisAsthmaBack PainBreast LumpBronchitisBruise EasilyCancerChest PainCold ExtremetiesConstipationCrampsDepressionDiabetesDigestion ProblemsDizzinessEars RingExcessive MenstruationEye Pain or DifficultiesFatigueFrequent UrinationHeadacheHemorrhoidsHigh Blood PressureHot FlashesIrregular Heart BeatIrregular CycleKidney InfectionKidney StonesLoss of MemoryLoss of BalanceLoss of SmellLoss of TasteNeck Pain or StiffnessNervousnessNosebleedsPacemakerPolioPoor PostureProstate TroubleSciaticaSexually Transmitted InfectionShortness of BreathSinus InfectionSleep Problems or InsomniaSpinal CurvaturesStrokeSwelling of AnklesSwollen JointsThyroid ConditionTuberculosisUlcersVaricose VeinsOtherNone of the Above
Should be Empty:

New Patient Health History Form

Patient Data

Insurance Information

Signatures

Medical History

Have you ever:

Family History

Habits