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New Patient Registration

  • 1 Patient Demographics
    Patient Information
    Sex
    Patient Address
    Patient Contact Information
    Marital Status
    Employee Detail
    Whom may we thank for referring you to this office?
  • 2 Emergency Contact
    Emergency Contact
    Emergency Contact Info
  • 3 Insurance Information
    Select Type
  • 4 History of Complaint
    Primary Complaint
    Please describe the issue
    Please choose the type of pain and show us where
    Is your problem the result of any type of accident?
    Other
    Do you have any problem(s)?
    When is the problem at its worst?
    How long does it last?
    Condition(s) ever been treated by anyone in the past?
    Primarily condition Pain level
    What is your pain RIGHT NOW?
    What is your TYPICAL or AVERAGE pain?
    What is your pain level AT ITS BEST (How close to “0” does your pain get at its best)?
    What is your pain level AT ITS WORST (How close to “10” does your pain get at its worst)?
  • 5 Nerve System Profile
    Have you had a recent auto accident?
    Type of impact
    Do you feel strain or stress on your body from work?
    Does your job require you remain in long term stressful postures?
    Spinal traumas in the past?
    Trauma as a child
    Work around the house
  • 6 Other Conditions

    Please mark any other symptoms you have experienced marking the following:

    Headache
    Pregnant
    Dizziness
    Prostate Problems
    Ulcers
    Neck Pain
    Frequent Colds/Flu
    Loss of Balance
    Impotence/Sexual Dys fun
    Heartburn
    Jaw Pain,TMJ
    Fainting
    Digestive Problems
    Heart Problem
    Shoulder Pain
    Tremors
    Double Vision
    Colon Trouble
    High Blood Pressure
    Upper Back Pain
    Chest Pain
    Blurred Vision
    Diarrhea/Constipation
    Low Blood Pressure
    Mid Back Pain
    Painw/Cough/Sneeze
    Ringing in Ears
    Menopausal Problems
    Asthma
    Low Back Pain
    Foot or Knee Problems
    Hearing Loss
    Menstrual Problem
    Difficulty Breathing
    Hip Pain
    Sinus/Drainage Problem
    Depression
    PMS
    Lung Problems
    Back Curvature
    Swollen/Painful Joints
    Irritable
    Bed Wetting
    Kidney Trouble
    Scoliosis
    Skin Problems
    Mood Changes
    Learning Disabilty
    Gall Bladder Trouble
    Numb/Tingling arms, hands,fingers
    ADD/ADHD
    Eating Disorder
    Liver Trouble
    Numb/Tingling legs, feet,toes
    Allergies
    Trouble Sleeping
    Hepatitis(A,B,C)
    Do you take any other medical/psychiatric conditions that have been previously diagnosed:
    Do you have any previous surgeries or other major medical procedures you have had:
    Do you have any other List Prescription & Non-Prescription drugs you take & How long you have been taking them:
    Is there any other injury(s) to your spine, minor or major, that the doctor should know about:
  • 7 Activities of Daily Living
    Daily Activities: Effects of Current conditions On Performance

    Please identify how your current condition is affecting your ability to carry out activities that are routinely part of your life:

    Bending
    Concentrating
    Doing computer Work
    Gardening
    Playing Sports
    Recreation Activities
    Shoveling
    Sleeping
    Watching TV
    Carrying
    Dancing
    Dressing
    Lifting
    Pushing
    Rolling Over
    Sitting
    Standing
    Working
    Climbing
    Doing Chores
    Driving
    Performing Sexual Activity
    Reading
    Running
    Sitting to Standing
    Walking
  • 8 Past History
    Have you suffered with any of your current complaints or a similar problem in the past?
    Other forms of treatment tried
    What were the results
    Please identify any and all types of jobs you have had in the past that have imposed any physical stress on you or your body
    If you have ever been diagnosed with any of the following conditions, please indicate below:
    Broken Bone
    Dislocations
    Tumors
    Rheumatoid Arthritis
    Fracture
    Disability
    Cancer
    Heart Attack
    Osteo Arthritis
    Diabetes
    Cerebral Vascular
    Other serious conditions
    Have you tested with high triglycerides or high cholesterol?
    Have you tested with high blood pressure?
    Are you diabetic, Have you been diagnosed as pre-diabetic or with metabolic syndrome?
    Do you eat breakfast daily from Monday to Friday?
    How many days per week do you skip one meal?
    How many fast food, refined foods, or pre-pared meals do you eat per week?
    How many servings of fruit do you have on a given day?
    How many servings of vegetables do you have on a given day?
    Do you regularly drink (1 or more per day) any of the following?
    Please list any supplements you take regularly:
  • 9 Social History
    Do you smoke?
    Smoking
    How often smoke
    Alcoholic Beverage: consumption occurs
    Recreational Drug use
    How does your present problem affect the following:
    Hobbies
    Recreational Activities
    Exercise Regime
  • 10 Family History
    Does anyone in your family suffer with the same condition(s)?
    If yes whom?
    Have they ever been treated for their condition?
    Any other hereditary conditions the doctor should be aware of?
  • 11 Patient Health and Nutrition Survey
    We recognize a large percentage of our patients have been asking about natural ways to address their health issues. In response to your concerns we have done extensive research to find the most advanced and unique health & wellness programs to bring to you. Please take a moment to give us your thoughts on how to better serve all your health needs.
    INDENTIFYING YOUR HEALTH GOALS:
    To help our office understand your wellness goals and give you the type of care that you want, please use this chart to answer the questions below it.
    Score Your Concern
    -5 I have serious concerns about my overall health.
    -4 I feel worried about my health.
    -3 I have constant concerns that affect my health.
    -2 I have health challenges that affect my on a daily basis.
    -1 I have some minor complaints about my health.
    0 I feel okay about my health with no complaints.
    +1 I feel good most days.
    +2 I feel well on a daily basis.
    +3 I feel energetic and healthy.
    +4 I feel active, energenic, and fit.
    +5 I feel great and am proactive about my health.
    What number above best describes how you feel about your health today?
    What number above do you want to achieve regarding your health?
  • 12 Identifying Your Health Goals
    Are you presently taking any type of nutritional supplements (such as vitamins, minerals, antioxidants, herbs, amino acids, fish oils,etc)?
    Who recommended you to take these supplements? Check all that apply.
    Where did you purchase these supplements? Check all that apply.
    Would you prefer that your doctor recommend specific supplements based on your specific health needs?
    If we offered a simple,non-invasive,genetic testtode termine what supplemental regimen is best for you based on your genetic/DNA variations,and,if we could customize your supplements to your specific needs, simplify the way you take your supplements,and increase the effectiveness of them,would you consider:
    Taking the Genetic test?
    Purchasing the recommended supplements?
    Bring in your Own test results
    If we offered a comprehensive weight loss management and continuing weight maintenance program with coaching and supervision, would you consider it?
    Please indicate the areas of health that you want to improve:
    If you could improve ONE thing about your health,what is your priority?
  • 13 Initial Fitness Profile
    Do you exercise?
    How willing are you to change any of these things to reach your health goals?
  • 14 Initial Toxicity Profile
    Are you regularly exposed to cleaning products or industrial chemicals?
    Have you ever noticed mold growing in your home or your place of work?
    Does your home, work, school, or car have damp or mildew smell?
    Have you received a full standard profile of vaccinations?
    Do you receive yearly flu shots?
    Have any members of your family been diagnosed with fibromy algia, chronic fatigue or multiple chemical sensitivities?
    Do you have symptoms of hormonal system imbalance (thyroid, reproductive, adrenal)?
  • 15 Initial Stress Profile
    Do you get an average of 8 hours of sleep per night
    Do you average less than 7 hours of sleep per night
    Do you ever take pills to go to sleep or relax
    Do you often feel short on time and procrastinate on projects?
    Do you experience feelings of anxiety about completing tasks?
    Do you feel like you don't give enough time or attention to important areas in your life like family, personal growth, or a hobby?
    Do you rely more on your memory than a planner and action list to get things done?
    Do you take time to pray, meditate, or visualize on a regular basis?
  • 16 Finish