Are you a new patient?

Yes

No

Are you a former patient?

Yes

No

Prefix *

First Name *

Middle Initial

Last Name *

Address:*

Address line 2:

City:*

State:*

Zip Code:*

Email address*

Phone*

Cell phone

Date of Birth *

Age

Occupation

Employer/School

Does your company offer you a gym membership as part of your benefit plan?

Yes

No

Do you have a flexible spending account?

Yes

No

Do you have a health savings account?

Yes

No

Do you have children?

Yes

No

Spouse's Name

Do you have a family insurance plan?

Yes

No

Reason for Visit*

When did your symptoms appear*

Is this condition getting progressively worse?

Yes

No

What treatment have you already received for your condition?

Name and Address of other doctor(s) who have treated you for your condition*

Injuries/Surgeries you have had*

Surgeon

Facility

Falls

Head Injury

Broken Bones

Dislocations

Date of last Physical Exam

Date of last Blood Test

Date of last Spinal Exam

Date of last MRI, X-Ray, CT/Bone Scan

Are you pregnant?

Yes

No

Due date

Do you have an irregular menstrual cycle?*

Yes

No

Exercise

None

Moderate

Daily

Heavy

Work Activity

Sitting

Standing

Light Labor

Heavy Labor

Substance use

Smoking:

Packs wkly

Alcohol:

Daily

Coffee/Caffeinated Drinks:

Cups/Day

Please list any medications you are taking*

Please list any dietary supplements you are taking

Please list any known allergies (peanuts, latex, eggs, shellfish)*

Emergency Contact

Relationship

Phone

Is condition due an accident?

Yes

No

Type of accident

Auto

Work

Home

Other

To whom have you made a report of your accident?

Auto Insurance

Employer

Workers Comp.

Other

Attorney Name (if applicable)

Welcome Sheet

Patient Information

Patient Condition

Medical Conditions

In Case Of Emergency (Please Contact)

Accident Information