Patient Information
New Patient Information
Email address *
Last Name, First Name , Middle Initial *
Your answer
Nickname
Your answer
Address, City, State, Zip *
Your answer
Primary Phone Number *
Your answer
Alternate Phone Number
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Occupation
Your answer
Employer
Your answer
Emergency Contact Person Name, Phone # *
Your answer
I give Horbach Chiropractic/BeStrong4life and its representatives permission to communicate to me via the contact information above *
What is your NUMBER ONE concern or area of pain *
Your answer
Please rate the level of pain on the following scale: 0 is no pain 10 is severe pain. *
When did this problem start? *
Your answer
Describe the onset *
How often do you experience the pain? *
Required
What increases your pain? *
Your answer
What decreases your pain? *
Your answer
Have you experienced this problem before? *
If yes when
Your answer
Any other areas currently bothering you? Please rate your pain for each using the same scale
Your answer
Have you ever been involved in a motor vehicle crash? *
If yes when?
Your answer
Did you sustain injuries?
If yes please explain
Your answer
Have you ever been injured at work? *
If yes when? Please explain
Your answer
List all the medications you are currently taking (prescribed and over the counter)
Your answer
List all the surgeries you have had (include date)
Your answer
Have you given birth?
How many children?
Your answer
Vaginal or Cesarean Section?
Your answer
If you have experienced any of the following conditions select Currently Experiencing or Experienced in the Past. Check all that apply
Currently
Past
heart attack
stroke
arthritis
gall bladder trouble
diabetes
glaucoma
fainting spells
kidney stones
difficulty with urination
bloody stools
cancer
asthma
prostate trouble
anemia
diverticulosis
menstrual cramping
AIDS
ulcers
chest pain
shortness of breath
dizziness
loss of memory
general fatigue
sudden weight loss
constipation
diarrhea
soreness in joints
loss of hearing
nausea
muscle cramping
migraine
epilepsy
ears ringing
headache
syphilis
sprained ankle
gout
tuberculosis
difficult bowel movements
joint replacement
knee/hip replacement
broken bones
If broken Bones please specify
Your answer
Anything other conditions you would like the doctor to know about?
Your answer
Do you Participate in any of these general activities? Check all that apply
Exercise, Swim, Lift weights/weight Machine, jog How many times per week?
Your answer
Computer use, Television, Play video games: How many hours per day?
Your answer
I certify that I have read and understand the above information to the best of my knowledge. The questions above have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize this office to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such chiropractic care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to this office benefits otherwise payable to me. I understand that my insurance carrier may pay less that the actual bill for services. I agree to responsible for payment of all services rendered on my behalf or my dependents. Please type your full name below to acknowledge. *
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Horbach Chiropractic. Report Abuse