New Patient Intake Form 

Patient Information:

Gender:

How did you hear about us?

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About you:

Whats your main focus?

In a few sentences explain your complaint/injury. Please detail when, how, and where it began.

How often do you experience pain from this condition?
Does this condition interfere with your sleep?
Does this condition affect your appetite?
Does this condition interfere with any of your daily activities or routines?
Has it affected your work?
Does the weather affect your pain?
Have you seen anyone else for this condition?
Have you ever had this same/similar condition?
Have you had previous chiropractic care?

List all current vitamins, minerals, supplements or herbs: (name, amount, frequency and reason for use)

List all current medications: (name, amount, frequency and reason for use)

Have you ever broken a bone?
Had any major sprains/strains?
Been hospitalized?
Had surgery?
Been struck unconcious?
Been in an auto accident?
Had a stroke?

Please list diagnosed health conditions or deaths within your family and their relationship to the patient

Please list any of the following conditions that apply to you below:

  • Allergies

  • Alcoholism

  • Anemia

  • Arteriosclerosis

  • Arthritis

  • Asthma

  • Autoimmune disease

  • Back Pain

  • Bleeding disorders

  • Breast Lump

  • Bronchitis

  • Bruise easily

  • Cancer

  • Cataracts

  • Chest pain

  • Congestive heart disease

  • Cold extremities

  • Constipation

  • COPD/Emphysema

  • Cramps

  • CVA/Stroke/ TIA

  • Dementia/Alzheimer's

  • Depression

  • Diabetes

  • Digestion Problems

  • Emotional/Mental disorders

  • Digestion problems

  • Diagnosed emotional/mental  disorders

  • Epilepsy

  • Excessive menstruation

  • Eye pain/difficulties

  • Fatigue

  • Frequent urination

  • Gallbladder disease/stones

  • Glaucoma

  • Gout

  • Headache

  • High Blood Pressure

  • Hot flashes

  • Irregular heart beat

  • Irregular menstrual cycle

  • Kidney infection

  • Kidney stones

  • Liver disease/cirrhosis

  • Loss of memory

  • Loss of balance

  • Loss of smell

  • Loss of taste

  • Loss of hearing

  • Lung disease

  • Macular degeneration

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Authorization:

I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic. I authorize this information to be submitted to this office of chiropractic through email. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.

Please select the button below if you agree with this statement above and date below.
  • Migraines

  • Nosebleeds

  • Pacemaker

  • Parkinson's

  • Polio

  • Poor posture

  • Prostate issues

  • Retinal disease

  • Sciatica

  • Seizures

  • Shortness of breath

  • Sinus infection

  • Sleep problems/insomnia

  • Skin sensitivity

  • Smoked

  • Spinal curvatures

  • Stroke

  • Swelling of the ankles

  • Swollen joints

  • Thyroid condition

  • Ulcers

  • Varicose veins

  • Venereal disease

  • Other

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7021 Kewanee Ave, Suite 8-101

Lubbock, Tx. 79424

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