New Patient Intake Form Step 1 of 3 33% Personal InformationName* First Last GenderMaleFemaleDate of Birth* HeightSelect4' 5"4' 6"4' 8"4' 9"4' 10"4' 11"5' 0"5' 1"5' 2"5' 3"5' 4"5' 5"5' 6"5' 7"5' 8"5' 9"5' 10"5' 11"6' 0"6' 1"6' 2"6' 3"6' 4"6' 5"6' 6"6' 7"6' 8"6' 9"6' 10"6' 11"7' 0"7' 1"7' 2"7' 3"7' 4"7' 5"7' 6"Weight - lbsMarital StatusSelectSingleMarriedDivorcedWidowedOtherContact InformationEmail* Primary Phone*This 10 digit number will be used to check you in at the Patient Check-In terminal at Z Chiropractic Center.Secondary PhoneWork PhonePrimary Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact InformationEmergency Contact PhoneRelationshipInsurance & Payment InformationWhat is the purpose of your visit?Wellness VisitPersonal InjuryWorkplace InjuryAuto AccidentFor auto accident claims, please fill out the following information:Insurance Company NameClaim #Claim Adjuster's NameClaim Adjuster's Phone NumberInsurance Company Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How would you like to pay for care?Personal InsuranceThird-Party InsuranceNo Insurance, Self-PayInsurance Company NameID/Policy #Insured's Date of Birth Personal Health HistoryFamily/Primary Care PhysicianDo you have a primary care physician?YesNoName of Primary Care Physician (optional) First Last Physician's Phone NumberHave you had previous chiropractic care?YesNoPlease list any health conditions that you have been treated for in the last year:ConditionDate of Onset (Approx.)Current/Resolved? Are you pregnant, or have you had any signs of pregnancy?YesNoAre you planning to get pregnant in the next 12 months?YesNoAre you currently using any medications?YesNoList current medicationsNameDose (mg)Tablets/dayLength of useReason for use To add more rows press the "+" to the right of the row.Are you currently taking any vitamins, minerals, supplements or herbs??YesNoList current vitamins, minerals, supplements, or herbsNameDose (mg)Tablets/dayLength of useReason for use To add more rows press the "+" to the right of the row.Personal Incident HistoryBroken Bones?YesNoList all broken bones.Broken Bone (left/right)Date of Fracture (Approx.) Been Hospitalized?YesNoHospitalization DetailsPurpose of VisitDate of Visit (Approx.) Have you been in an auto accident within the past 5 years?YesNoAuto Accident DetailsDate of AccidentInjuries Acquired Did you get professional care/treatment?YesNoHad Major Sprains/Strains?YesNoDid you get professional care/treatment?YesNoBriefly Explain(date, brief description of cause, reason and/or circumstances)Had Surgery?YesNoPast SurgeriesReason for SurgeryDate of Surgery (approx.) Been Struck Unconscious?YesNoDid you get professional care/treatment?YesNoHad a Stroke?YesNoStroke DetailsDate of Stroke (approx.)Residual Symptoms? Family Health HistoryPlease list any family member's diagnosed health conditions and untimely deaths.ConditionRelationshipAgeLiving/Deceased Family members include: Parents and siblings and maternal and paternal grandparents/aunts/uncles. (Examples: arthritis, cancer, diabetes, heart disease, kidney disease, high cholesterol, etc.)Social History & Life ChoicesOn average, how many hours of sleep do you get each night?Less than 44 to 66 to 8More than 8Do you feel well rested upon waking?YesNoHow would you rate your stress levels on average?NoneMildModerateHighWhat are your current stressors over the past 6 months?AlcoholDailyWeeklyOccasionallyNeverDiet Food ProductsDailyWeeklyOccasionallyNeverEnergy Products or Over-the-Counter StimulantsDailyWeeklyOccasionallyNeverFresh & Homemade FoodsDailyWeeklyOccasionallyNeverSoft DrinksDailyWeeklyOccasionallyNeverWater1-2 cups/day3-4 cups/day5-6 cups/day7 or more cups/day1 cup = 8fl oz.Caffeine Drinks & Products1 cup/day2-3 cups/day4 or more cups/dayNeverRecreational DrugsDailyWeeklyOccasionallyNeverPreprocessed, Packaged, & Restaurant FoodDailyWeeklyOccasionallyNeverTobaccoDailyWeeklyOccasionallyNeverHow many packs a day?<112>3How many packs a week?<112>3 Chiropractic ExperienceHow did you hear about us?* Internet Mailing Friend or Family Member Sign Newspaper Community Event Please select all that applyReason for this VisitDescribe the reason for your visitWhat was the cause of your condition?Home InjuryWork InjurySportsChronic DiscomfortAuto AccidentDate of Initial Injury (approx.) In what areas has this impacted your life? Work Sleep Daily Routine Other Activities Select all that apply.Since the onset has this concern:WorsenedStayed the sameImprovedWhat symptoms are you experiencing? Achy/Dullness Sharp/Stabbing Pins/Needles Radiating Pain Numbness/Tingling Throbbing Burning Cramping Other Has this injury occurred in the past?YesNoPlease provide details of previous episodeDate of OccurrenceResolved/Unresolved?Describe Occurrence Have you seen other doctors for this concern?YesNoName of Doctor Type of treatment received? Chiropractic Massage Surgery Accupuncture Medication Other Select all that apply.Other treatment receivedOverall experience with previous doctor?GoodIndifferentBadGoals for Your CarePeople see a chiropractor for a variety of reasons. Sme go for relief of pain, some to correct the cause of pain and others for correction of whatever is malfunctioning in their body. Your doctor will weigh your needs and desires when recommending your care program.Please select the type of care you wish to receive. Relief care: Symptomatic relief of pain or discomfort Corrective care: Correcting and relieving the cause of the problem as well as the symptom Comprehensive care: Bring whatever is malfunctioning in the body to the highest state of health possible with Chiriopracitic care I want the Doctor to select the type of care appropriate for my condition Health Problems & Concerns:Please select all that you have had or currently have Allergies Alcoholism Anemia Anxiety 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 Diagnosed emotional/mental disorders Dizziness Epilepsy Excessive Menstruation Eye Pain or Difficulties Fatigue Frequent Urination Gallbladder disease/stones Glaucoma Gout Headache Hemorrhoids 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 Lung disease Macular Degeneration Migraines Nosebleeds Pacemaker Parkinson's Polio Poor Posture Prostate Trouble Retinal Disease Sciatica Seizures Shotness of Breath Sinus Infection Sleep Problems/Insomnia Skin Sensitivity Smoked Spinal Curvatures Stress Stroke Swelling of Ankles Swollen Joints Thyroid Condition Tuberculosis Ulcers Varicose Veins Venereal Disease Other Please list any allergies you haveHave you had any of these Cardiovascular Diseases? Myocardial infarction Hypertension Hypercholesterolemia Coronary artery disease Bypass surgery Please select all that apply.Do you have diabetes? If so what type?Type IType IIJuvenileDo you ave any stomach/digestive issues? Ulcers Reflux Irritable Bowel Syndrome Select all that apply.Finalizing FormPlease select the submit button to finalize your form and to submit it directly to AORA Wellness. All information that you have provided is confidential and will not be disclosed to any parties without prior signed authorization from you.