New Patient Intake Form Please enable JavaScript in your browser to complete this form.Today's Date *Name *FirstLastDate of birth *Gender *FemaleFemaleMaleOtherPrefer not to sayMarital statusSingleSingleMarriedWidowedHeight *WeightStreet address *City *State *Zip code *Phone number *Email *OccupationEmployerDo you have insurance *Choice 1YesNoIf you do have insurance, who is your insurance providerInsurance member numberInsurance group numberEmergency contact nameEmergency contact phone numberPrimary area of complaint *neck pain. mid back pain, lower back pain, etcAny other areas of complaintDoes any of the complaints radiate YesNoIf it does radiate, where todown left arm, down right leg, etcApproximate onset of primary complaintWhat may have caused primary complaint a fallafter a long drivea poor night sleeplifting an objecta slipafter reaching for an objectafter performing house hold choresafter performing some yard workafter sitting for a prolong periodexercisingassociated with a chronic illnessunknown originotherIf other, list causeRate the severity of primary complaint (0-10) *0 is least severe and 10 is the most severe012345678910How often is the primary complaint * comes and goesfrequentconstantreoccurringHow has the primary complaint change since the onset * samehas gotten worsthas gotten betterWhat term(s) describes your complaint best? Choose all that applyachingtightnessstiffnessburningintolerablesharpshootingstabbingthrobbingnumbesstinglingHave other health provider(s) preformed tests related to this condition noyesWhat treatment have you received for this condition up to now? Choose all that applynonemassageprescribed medicationover-the-counter medicationmedical injection treatmentacupuncturephysical therapychiropractic careotherWhat aggravates these complaints? Choose all that applyalmost any movementathletic activity and/or exercisebendingcarryinglitingchanging positionscoughing and/or sneezingdaily child or pet caregetting out of bed, chair or carpulling, pushing, or reachingraising arm above shoulderself care (dressing, bathing, etc)sitting for prolong periodsrunningstresssquatting or bendingwalkingworking at a desk/computerunknownWhat improves the condition(s) or gives you relief? Choose all the applynothingchiropractic treatmentprescription medicationscold packsheat packsstretchingrestexcersieworkacupuncturemassagephysical therapyover-the-counter medicationsotherHave you ever had any previous episodes of primary complaintno or yesnoyesDo you have any of the listed health condition(s)muscle bone or jointsnerves, headaches, dizziness or emotionalhead, eyes, nose or throatheart, blood pressure or circulationshortness of breath, coughing, asthma or other lung conditionsDo you have any of the listed health condition(s)stomach, bowels or digestive conditionsgenital, bladder or urinary conditionsdiabetes, thyroid or glandular conditionsskin or bleeding conditionsallergies or sensitivitiesFamily and personal historyyou had any surgical proceduresthere any past illnesses or conditions we should be aware ofyou have a past history of accidents or traumayou presently taking any medication(s)family illness history-such as: diabetes, cancer, hypertension, and progressive neurological diseasesIf any of the family and personal history apply, please list conditionsCurrent work habits-choose all that apply (copy)full-time (20-40+ hours/week)part-time (1-19 hours/week)studenthomemakerCurrent work situation-choose all that applypermanently fully disablepermanently partially disableunemployedcan not work due to current conditionPersonal social habits-choose all that applysmoke or use tobacco productsdrink alcoholdrink caffenineuse recreational drugsother, to be discussed with doctorPresent exercises habits-choose all that applyno current excercisesexercises dailyexercises 3+ times a weekcan not return to exercise due to current conditionother, to be discussed with doctorSocial media (King Chiropractic would like to follow you on social media. Please add kingchiroatx or input your handle for us to follow you)CommentsSubmit
