Patient Forms | Health4Life Chiropractic | Health4Life Chiropractic

1. Personal Data

First Name *

Last Name *

Date of Birth *

Age

Gender

Marital Status

Occupation

Employer

Number of Children

BSN / Social Security #

2. Contact & Address

Email Address *

Phone (mobile / home) *

Phone (work)

Referred By

Street Address

City

Postcode

Emergency Contact Name

Emergency Contact Phone

Spouse / Partner (if applicable)

Name

Occupation

Employer

Health Status

3. Current Complaints

Nature of Injury / Complaint

AutomobileWorkOther

Please Describe

Date of Injury

Date Symptoms Appeared

Have you ever had the same condition before?

NoYes

Other practitioners seen for this condition

Have you ever been under chiropractic care?

NoYes

4. Medical History

Have you been treated for any conditions in the last year?

NoYes

Date of Last Physical Exam

Is there a chance you are pregnant?

NoYes

Have you had X-rays taken?

NoYes

Current Medications (include dosage & condition)

Vitamins, Minerals or Herbs (include dosage & frequency)

5. Have You Ever…

6. Family History

Family members — present and past health conditions

e.g. heart disease, cancer, diabetes, arthritis, etc.

7. Daily Life & Symptoms

What activities aggravate your symptoms?

8. Habits

9. Have You Ever Suffered From…

Check all that apply.

Other (please specify)

10. Insurance Information

Name of party responsible for payment

Phone

Do you have health insurance?

NoYes

11. Consent & Signature

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me are charged as my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Full Name (as signature) *

Date *

I confirm that the information provided in this form is accurate and complete to the best of my knowledge. I consent to chiropractic examination and treatment as deemed necessary by Dr. Jahani. *

Habit	None	Light	Moderate	Heavy
Alcohol
Coffee
Tobacco
Drugs
Exercise
Sleep
Appetite
Soft Drinks
Water
Salty Foods
Sugary Foods
Artificial Sweeteners

New Patient Intake Form

1. Personal Data

2. Contact & Address

3. Current Complaints

4. Medical History

5. Have You Ever…

6. Family History

7. Daily Life & Symptoms

8. Habits

9. Have You Ever Suffered From…

10. Insurance Information

11. Consent & Signature