nycprimaryspine.com - PATIENT FORMS

PATIENT FORMS
PATIENT DATA
Name

First NameLast Name
Date

MonthDayYear
Date
Email
Your email will NOT be shared with any 3rd parties, and is used for occasional office announcements and promotions.
MAILING ADDRESS
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone (Work)
Please enter a valid phone number.
Telephone (Work)
Please enter a valid phone number.
Referred By
Age
Birth Date

MonthDayYear
Date
Social Security Number
Number of Children
Occupation
Employer
Marital Status
Spouse's Name
Spouse's Occupation
Spouse's Employer
Spouse's Health Status
Emergency Contact
Phone Number
Please enter a valid phone number.
* Your email will NOT be shared with any 3rd parties, and is used for occasional office announcements and promotions.
CURRENT COMPLAINTS
Nature of Injury

AutomobileWorkOther
Date of Injury

MonthDayYear
Date
Date symptoms appeared

MonthDayYear
Date
Have you ever had same condition?

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

YesNo
If yes, when?
INSURANCE INFORMATION
Name of party responsible for payment
Phone Number
Please enter a valid phone number.
Do you have health insurance?

YesNo
Name of company
* If an auto accident, please provide:
Insurance Company Name
Contact Person
Phone Number
Please enter a valid phone number.
Claim #
SIGNATURES
Name of the insured
MEDICAL HISTORY
Have you been treated for any conditions in the last year?

YesNo
If yes, please describe
Date of last physical exam

MonthDayYear
Date
Is there a chance that you are pregnant?

YesNo
Have you had X-rays taken?

YesNo
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 currently take? (Please list for what conditions, dosage, and frequency).
HAVE YOU EVER
Broken bones?

YesNo
If yes, Briefly Explain
Been hospitalized?

YesNo
If yes, Briefly Explain
Been in an auto accident?

YesNo
If yes, Briefly Explain
Had Sprains/Strains?

YesNo
If yes, Briefly Explain
Been struck unconscious?

YesNo
If yes, Briefly Explain
Had surgery?

YesNo
If yes, Briefly Explain
FAMILY HISTORY
Family Members - Present and past health conditions (Example: heart disease, cancer, diabetes, arthritis, etc.)
Do you experience pain every day?

YesNo
Do your symptoms interfere with daily life?

YesNo
Does pain wake you up at night?

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

YesNo
Do changes in weather affect your symptoms?

YesNo
Do you wear orthotics?

YesNo
Do you take vitamin supplements?

YesNo
What activities aggravate your symptoms?

YesNo
HABITS
Alcohol

NoneLightModerateHeavy
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
OTHER INFORMATION
Have you ever suffered from:

AlcoholismAllergiesAnemiaArteriosclerosisArthritisAsthmaBack PainBreast LumpBronchitisBruise EasilyCancerChest Pain/ConditionsCold ExtremitiesConstipationCrampsDepressionDiabetesDigestion ProblemsDizzinessEars RingExcessive MenstruationEye Pain or DifficultiesFatigueFrequent UrinationHeadacheHemorrhoidsHigh Blood PressureHot FlashesIrregular Heart BeatIrregular CycleKidney InfectionKidney StonesLoss of memoryLoss of balanceLoss of smellLoss of tasteLumps In BreastNeck Pain or StiffnessNervousnessNosebleedsPacemakerPolioPoor PostureProstate TroubleSciaticaShortness of breathSinus InfectionSleep problems or InsomniaSpinal CurvaturesStrokeSwelling of anklesSwollen JointsThyroid ConditionTuberculosisUlcersVaricose VeinsVenereal Disease
Should be Empty:

PATIENT FORMS

PATIENT DATA

MAILING ADDRESS

CURRENT COMPLAINTS

INSURANCE INFORMATION

SIGNATURES

MEDICAL HISTORY

HAVE YOU EVER

FAMILY HISTORY

HABITS

OTHER INFORMATION