New Patient Medical History
Intake Form
Email address *
What is today's date? *
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First Name
Your answer
Last Name
Your answer
Date of Birth:
MM
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DD
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YYYY
Phone Number *
Please enter 10 digit phone number (example: 123-456-7890)
Your answer
What is your home address? *
Your answer
Height *
Please enter height in feet ' and inches " (Example: 5' 4")
Your answer
Weight *
Your answer
Are you able to read and understand English? *
Are you currently being treated by a chiropractor?
Are you latex sensitive?
Do you smoke?
Do you have any allergies?
Please list any allergies or medication(s) you are allergic to.
Your answer
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?
Do you ever feel unsafe at home or has anyone hit you or tried to injure you in any way?
FOR WOMEN: Are you currently pregnant or think you might be pregnant?
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