New Patient Form Prior to your first visit, please fill out all 3 Sections of the New Patient Form. Thank you. (1) Patient & Medical Information (2) Chief Complaint (3) Family & Medical History Patient Information Last Name Ml First Name Age Male Female Address Date of Birth City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Coulmbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code E-mail Referred by Home # Cell # Work # Ext. Current Occupation Marital Status Married Single Widowed Divorced FAMILY PHYSICIAN Name     Dr. Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Coulmbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Medical Information FOR THE FOLLOWING CONDITIONS PLEASE CHECK: Previously had Currently have GENERAL Recent weight gain Recent weight loss Fatique Rheumatic Fever Loss of sleep Loss of appetite Polio Cancer of any kind INTEGUMENTARY (SKIN) Skin Problems Skin rashes Psoriasis Skin cancer Slow healing Discolorations Change in moles Scars Bruise easily Itching Change in skin color Sores NEUROLOGICAL Light headed/dizzy Fainting Disorientation Weakness Memory Loss Concussion Loss of Coordination Numbness Difficulty speaking Headaches Difficulty walking Tingling Multiple Sclerosis Migraines Stroke Tremors Parkinson's Disease Epilepsy/Seizures Alzheimer's Disease Disk Problem EYES, EARS, NOSE AND THROAT Vision problems Glaucoma Ear pain Sore throat Blurred vision Hearing loss Mouth sores Nose bleeds Double vision Ear noises Hoarseness Dental problems ENDOCRINE Hypothyroidism Hyperthyroidism Diabetes Goiter RESPIRATORY Coughing Pneumonia Superficial breathing Bronchitis Coughing up blood Difficulty breathing Chest pain Emphysema Chronic cough Asthma Tuberculosis Lung cancer CARDIOVASCULAR Pain over the heart Pressure over chest High blood pressure Shortness of breath Hearth attack Pain down left arm Low blood pressure Profuse sweating Irregular heartbeat Cardiomegaly High triglycerides Nausea Murmurs Swelling of ankles High cholesterol levels Vomiting GASTROINTESTINAL Gallbladder Problem Pain over stomach Constipation Blood in the stool Liver trouble Burning in stomach Diarrhea Mucus in stool Hepatitis Ulcers Hiatal hernia Pancreatitis Distress from greasy food Heartburn Colitis Colon cancer GENITOURINARY Painful urination Frequent urination Kidney infection Kidney stones Blood in urine Incontinence HEMATOLOGIC (BLOOD) Anemia Bleeding Disorder Sickle Cell Anemia Lymphoma MUSCULOSKELETAL Arthritis Head injury Cancer Muscle pain Osteoarthritis Neck injury Muscle weakness Gout Rheumatoid Arthritis Back injury Osteoporosis Scoliosis Bone Spurs Spinal trauma Muscular Dystrophy Lupus Broken Bones Birth trauma Scheuerman's disease Spina Bifida Compression Fracture Birth defects Joint pain Spondylolisthesis ALLERGIC/IMMUNOLOGIC Catch cold easely Frequent sinus trouble Frequent influenza Fever HIV AIDS Allergies Hay fever WOMEN ONLY Hysterectomy MEN ONLY Prostate trouble Prostate cancer

	New Patient Form Prior to your first visit, please fill out all 3 Sections of the New Patient Form. Thank you. (1) Patient & Medical Information (2) Chief Complaint (3) Family & Medical History Chief Complaint Last Name Ml First Name CURRENT CONDITION, WHAT BRINGS YOU TO YOUR OFFICE TODAY? Condition#1 Condition#2 Condition#3 PLEASE CLICK WHERE YOU EXPERIENCE THE PAIN Head Head Head Eye Eye Ear Ear Ear Neck Nose Nose Upper Back Mouth/Jaw Mouth/Jaw Mid Back Neck Neck Lower Back Chest Chest/Upper Back Tail Bone Abdomen Abdomen/Mid Back Shoulder Groin Lower Back Triceps Shoulder Groin/Tail Bone Elbow Biceps Shoulder Forearm Elbow Biceps/Triceps Wrist Forearm Elbow Hand/Fingers Wrist Forearm Thigh Hand/Fingers Wrist Knee Thigh Hand/Fingers Calf/Shin Knee Thigh Ankle Calf/Shin Knee Foot/Heel Ankle Calf/Shin Foot/Toes Ankle Foot/Toes/Heel HOW LONG HAVE YOU HAD THIS CONDITION? WHEN DID YOU FIRST NOTICE IT? Condition#1 Condition#2 Condition#3 DO YOU KNOW WHAT COULD HAVE CAUSED IT? HOW DID IT HAPPEN? Condition#1 Condition#2 Condition#3 PRIOR TREATMENT(S) FOR THIS CONDITION? IF SO, WHAT WAS THE TREATMENT AND DID IT HELP? Condition#1 Condition#2 Condition#3 WHAT MAKES YOUR CONDITION BETTER? WHAT MAKES IT WORSE? Condition#1 Condition#2 Condition#3 PLEASE DESCRIBE YOUR PAIN OR SENSATION? IS YOUR CONDITION CONSTANT OR DOES IT COME AND GO? Condition#1 Sharp Pain Dull Pain Aching Pain Throbbing Pain Shooting Pain Numbness Tingling Condition#1 Constant Intermittent Condition#2 Sharp Pain Dull Pain Aching Pain Throbbing Pain Shooting Pain Numbness Tingling Condition#2 Constant Intermittent Condition#3 Sharp Pain Dull Pain Aching Pain Throbbing Pain Shooting Pain Numbness Tingling Condition#3 Constant Intermittent DOES YOUR PAIN TRAVEL? IF SO FROM WHERE TO WHERE? Condition#1 Condition#2 Condition#3 PLEASE RATE YOUR PAIN TODAY (0 INDICATING NO PAIN 10 THE WORST YOU HAVE EVER HAD) Condition#1 0/10 1/10 2/10 3/10 4/10 5/10 6/10 7/10 8/10 9/10 10/10 Condition#2 0/10 1/10 2/10 3/10 4/10 5/10 6/10 7/10 8/10 9/10 10/10 Condition#3 0/10 1/10 2/10 3/10 4/10 5/10 6/10 7/10 8/10 9/10 10/10 PLEASE RATE YOUR PAIN WHEN IT FIRST STARTED (0 INDICATING NO PAIN 10 THE WORST YOU HAVE EVER HAD) Condition#1 0/10 1/10 2/10 3/10 4/10 5/10 6/10 7/10 8/10 9/10 10/10 Condition#2 0/10 1/10 2/10 3/10 4/10 5/10 6/10 7/10 8/10 9/10 10/10 Condition#3 0/10 1/10 2/10 3/10 4/10 5/10 6/10 7/10 8/10 9/10 10/10 IS YOUR CONDITION BETTER OR WORSE AT DIFFERENT TIMES OF THE DAY, MONTH OR SEASONS? PLEASE EXPLAIN Condition#1 Condition#2 Condition#3 ACTIVITY & REST Current Exercise Program Age of mattress Condition of mattress

	New Patient Form Prior to your first visit, please fill out all 3 Sections of the New Patient Form. Thank you. (1) Patient & Medical Information (2) Chief Complaint (3) Family & Medical History Family History Last Name Ml First Name PLEASE SELECT THOSE WHO HAVE HAD ANY OF THE FOLLOWING CONDITIONS: Osteoporosis N/A Myself Grandfather Grandmother Father Mother Brother Sister Cancer N/A Myself Grandfather Grandmother Father Mother Brother Sister Bleeding Disorder N/A Myself Grandfather Grandmother Father Mother Brother Sister Diabetes N/A Myself Grandfather Grandmother Father Mother Brother Sister Type of Cancer High Blood Pressure N/A Myself Grandfather Grandmother Father Mother Brother Sister Stroke N/A Myself Grandfather Grandmother Father Mother Brother Sister Heart Attack N/A Myself Grandfather Grandmother Father Mother Brother Sister Genetic Disorder N/A Myself Grandfather Grandmother Father Mother Brother Sister MULTIPLE FAMILY MEMBERS WITH THE SAME DISEASE, PLEASE LIST: PLEASE LIST DISEASE RELATED DEATHS IF APPLICABLE: Mother's Age Cause of death Grandfather's Age Cause of death Grandmother's Age Cause of death Father's Age Cause of death Grandfather's Age Cause of death Grandmother's Age Cause of death Personal Medical History ALLERGIES Please list all known allergies Other Any other diseases not previously mentioned? MEDICATIONS & SUPPLEMENTS Please list ALL Medications, Nutritional Supplements (S), Herbs (H), Vitamins (V) and Over the Counter Drugs (OTC): Medication Milligrams/day S,H,V,OTC Milligrams/day Medication Milligrams/day S,H,V,OTC Milligrams/day Medication Milligrams/day S,H,V,OTC Milligrams/day Medication Milligrams/day S,H,V,OTC Milligrams/day Medication Milligrams/day S,H,V,OTC Milligrams/day Medication Milligrams/day S,H,V,OTC Milligrams/day Medication Milligrams/day S,H,V,OTC Milligrams/day Medication Milligrams/day S,H,V,OTC Milligrams/day ACCIDENTS & INJURIES Please list any past accidents, severe falls, major injuries as well as fractures and dislocations Year Type of accident Residual problem Year Type of accident Residual problem Year Type of accident Residual problem Year Type of accident Residual problem SURGERIES & HOSPITALIZATION Please list any past surgeries and hospitalizations Year Type Residual problem Year Type Residual problem Year Type Residual problem Year Type Residual problem Patient Signature: Last Name First Name Date

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