New Patient Medical History
Intake Form
Email *
What is today's date? *
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First Name
Last Name
Date of Birth:
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Phone Number *
Please enter 10 digit phone number (example: 123-456-7890)
What is your home address? *
Height *
Please enter height in feet ' and inches " (Example: 5' 4")
Weight *
Are you able to read and understand English? *
Are you currently being treated by a chiropractor?
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Are you latex sensitive?
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Do you smoke?
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Do you have any allergies?
Please list any allergies or medication(s) you are allergic to.
Have you noted any of the following (check all that apply)? *
Required
Have you ever been diagnosed with any of the following conditions (check all that apply)? *
Required
Has anyone in your immediate family (parents, brother, sisters) EVER been diagnosed with any of the following conditions (check all that apply)? *
Required
During the past 2 weeks have you been feeling down, depressed or hopeless? *
During the past 2 weeks have you been bothered by having little interest or pleasure in doing things? *
Is this something with which you would like help?
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Do you ever feel unsafe at home or has anyone hit you or tried to injure you in any way?
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FOR WOMEN: Are you currently pregnant or think you might be pregnant?
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