Patient Form Online - Hammer & Forge Chiropractic

1. Primary Patient Information

Many of the items on this form are required. If the areas are not applicable, please fill in "none" as your answer!

Name*

First Middle Last

Email*

Gender*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone Number*

Cell Phone (if Different)

Preferred Method of Contact*

Employer Name*

Occupation*

Age*

Date of Birth*

Marital Status*

Spouse Name

Referred By

Number of Children

Children Age, Name & Gender

2. Healthcare Concerns

Concern #1*

Severity (Scale 1-10)*

When did it begin?*

Had Before (When)*

Did it begin with an Injury?*

How frequent are the symptoms?*

Concern #2

Severity (Scale 1-10)

When did it begin?

Had Before (When)

Did it begin with an Injury?

How frequent are the symptoms?

Concern #3

Severity (Scale 1-10)

When did it begin?

Had Before (When)

Did it begin with an Injury?

How frequent are the symptoms?

Concern #4

Severity (Scale 1-10)

When did it begin?

Had Before (When)

Did it begin with an Injury?

How frequent are the symptoms?

Concern #5

Severity (Scale 1-10)

When did it begin?

Had Before (When)

Did it begin with an Injury?

How frequent are the symptoms?

Seen other doctors for these conditions?*

Chiropractor?*

Medical Doctor?*

3. Medical History

List all Surgical Operations & Years*

List all Prescription & Over-Counter Medications*

When was your last auto accident?

Have you had previous Chiropractic care?*

If so, Dr. Name and Date Seen?

Have you ever been knocked unconscious?*

Have you ever fractured a bone?*

If knocked unconscious or fractured a bone, please describe

Other Trauma?

4. Insurance Information

Primary Insurance Carrier*

Name of Insured*

Insured Birthdate*

Insured Member ID*

Secondary Insurance Carrier

Secondary Name of Insured

Secondary Insured Birthdate

Secondary Insured Member ID

Contact in Case of Emergency*

Emergency Contact Phone Number*

Social Security Number

5. Family Health History

Current Problems You Have*

6. Social History

Smoking*

None
Cigars
Pipes
Cigarettes

How Often?

Daily
Weekends
Occasionally
Never

Exercise | How Often?*

Daily
Weekends
Occasionally
Never

Hobbies - Recreational Activities - Exercise

How does your present problem affect the following?

What daily activities are being restricted by your health issues?*

Please Select the Number that Best Describes the Question Being Asked.

Select pain level for each issue you are experiencing on a scale of "0-10". With 0 being "No Pain" to 10 being "Worst Possible Pain".

Issue #1*

What is you pain RIGHT NOW?*

What is your TYPICAL or AVERAGE pain?*

What is your pain level AT ITS BEST (how close to "0" does your pain get at its best)?*

What is your pain level AT ITS WORST (how close to "10" does your pain get at its worst)?*

Issue #2

What is you pain RIGHT NOW?

What is your TYPICAL or AVERAGE pain?

What is your pain level AT ITS BEST (how close to "0" does your pain get at its best)?

What is your pain level AT ITS WORST (how close to "10" does your pain get at its worst)?

Issue #3

What is you pain RIGHT NOW?

What is your TYPICAL or AVERAGE pain?

What is your pain level AT ITS BEST (how close to "0" does your pain get at its best)?

What is your pain level AT ITS WORST (how close to "10" does your pain get at its worst)?

Other Comments

Comments

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New Patient Form

1. Primary Patient Information

2. Healthcare Concerns

3. Medical History

4. Insurance Information

5. Family Health History

6. Social History

How does your present problem affect the following?

Please Select the Number that Best Describes the Question Being Asked.