Beavercreek Chiropractic & Injury Treatment Center

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New Patient Form
(*) denotes required field

First & Last Name(*) Invalid Input
Middle initial Invalid Input
Nickname Invalid Input
Email(*) Invalid Input
Can we send emails
(appt info, announcements, text msg, etc.)(*)
Invalid Input
Address(*) Invalid Input
City(*) Invalid Input
State(*) Invalid Input
Zip(*) Invalid Input
Work phone (xxx-xxx-xxxx) Invalid Input
Home phone (xxx-xxx-xxxx) Invalid Input
Cell phone (xxx-xxx-xxxx) Invalid Input
Cell carrier Invalid Input
Date of birth(*) Invalid Input
Gender(*) Invalid Input
Referred by Invalid Input
Race Invalid Input
Language Invalid Input
Prim. care physician Invalid Input
Prim. care physician ph# (xxx-xxx-xxxx) Invalid Input
Occupation Invalid Input
Employer Invalid Input
Marital status Invalid Input
Spouse/parents name Invalid Input
Spouse/parents occupation Invalid Input
Spouse/parents employer Invalid Input
Emerg. contact name Invalid Input
Emerg. contact ph#
(xxx-xxx-xxxx)
Invalid Input
   
Injury type Invalid Input
Describe injury Invalid Input
Date of injury Invalid Input
Current symptoms Invalid Input
Date of symptoms Invalid Input
Ever had same condition(*) Invalid Input
If have had same condition,
approximately when
Invalid Input
Other practitioners seen for
your injury/condition
Invalid Input
Previously been under
Chiropractic care(*)
Invalid Input
Describe any previous
Chiropractic care
Invalid Input
Guarantor/Subscriber Invalid Input
Guarantor's phone# (xxx-xxx-xxxx) Invalid Input
Guarantor's employer Invalid Input
Guarantor's DOB Invalid Input
Guarantor's relationship
to patient
Invalid Input
Do you have insurance(*) Invalid Input
Claims mailing address Invalid Input
Insurance company Invalid Input
Ins. company ph# (xxx-xxx-xxxx) Invalid Input
Insurance policy# Invalid Input
Group number Invalid Input
Do you have secondary insurance(*) Invalid Input
Secondary insurance company Invalid Input
2nd insurance ph# (xxx-xxx-xxxx) Invalid Input
Insurance policy# Invalid Input
Group number Invalid Input
Auto-accidents or
work injury;
Date of injury Invalid Input
Insurance company or
responsible party
Invalid Input
Ins. contact person Invalid Input
Phone (xxx-xx-xxxx) Invalid Input
Claim# Invalid Input
Claims mailing address Invalid Input
   
Have you been treated for
any cond. in the last year(*)
Invalid Input
If treated, please describe. Invalid Input
Date of last physical exam Invalid Input
Any chance you're pregnant(*) Invalid Input
Had an x-ray taken(*) Invalid Input
If x-ray taken, when and where Invalid Input
List meds taking & cond.
(dosage & amounts)
Invalid Input
Vitamins, minerals or herbs
taken? (for what condition, dosage & frequency)
Invalid Input
Broken bones(*) Invalid Input
Bones explain briefly Invalid Input
Been hospitalized(*) Invalid Input
Hospital explain briefly Invalid Input
Been in an auto accident(*) Invalid Input
Auto accident explain briefly Invalid Input
Had sprains or strains(*) Invalid Input
Explain sprains or strains Invalid Input
Been struck unconscious(*) Invalid Input
Explain unconscious event Invalid Input
Had surgery(*) Invalid Input
Explain surgery event Invalid Input
   
Do you experience pain every day(*) Invalid Input
Your symptoms interfere with
your daily life?(*)
Invalid Input
Pain wake you up at night(*) Invalid Input
Your symptoms worse at
certain times of day(*)
Invalid Input
Changes in weather affect
symptoms?(*)
Invalid Input
Do you wear orthotics(*) Invalid Input
Take vitamins supplements(*) Invalid Input
Activities that aggravate
symptoms
Invalid Input
Alcohol consumption(*) Invalid Input
Caffeine consumption(*) Invalid Input
Drug consumption(*) Invalid Input
Exersice(*) Invalid Input
Tobacco use(*) Invalid Input
If smoker how much Invalid Input
Seasonal allergies(*) Invalid Input
Food allergies(*) Invalid Input
Medication allergies(*) Invalid Input
Briefly explain allergies Invalid Input
Family medical history
(i.e. heart disease, cancer,
diabetes,arthritis, etc.)
Invalid Input
   
Ever suffered from?
Alcoholism(*) Invalid Input
Anemia(*) Invalid Input
Arteriosclerosis(*) Invalid Input
Arthritis(*) Invalid Input
Asthma(*) Invalid Input
Back pain(*) Invalid Input
Breast lump(*) Invalid Input
Bronchitis(*) Invalid Input
Bruise easily(*) Invalid Input
Cancer(*) Invalid Input
Chest pain Conditions(*) Invalid Input
Cold extremities(*) Invalid Input
Constipation(*) Invalid Input
Cramps(*) Invalid Input
Depression(*) Invalid Input
Diabetes(*) Invalid Input
Digestion problems(*) Invalid Input
Dizziness(*) Invalid Input
Ear rings(*) Invalid Input
Excessive menstruation(*) Invalid Input
Eye pain difficulties(*) Invalid Input
Fatigue(*) Invalid Input
Frequent urination(*) Invalid Input
Headache(*) Invalid Input
Hemorrhoids(*) Invalid Input
High blood pressure(*) Invalid Input
Hot flashes(*) Invalid Input
Irregular heart beat(*) Invalid Input
Irregular cycle(*) Invalid Input
Kidney infection(*) Invalid Input
Kidney stones(*) Invalid Input
Loss of memory(*) Invalid Input
Loss of balance(*) Invalid Input
Loss of smell(*) Invalid Input
Loss of taste(*) Invalid Input
Neck pain or stiffness(*) Invalid Input
Nervousness(*) Invalid Input
Nose bleeds(*) Invalid Input
Pacemaker(*) Invalid Input
Polio(*) Invalid Input
Poor Posture(*) Invalid Input
Prostate trouble(*) Invalid Input
Sciatica(*) Invalid Input
Shortness of breath(*) Invalid Input
Sinus infection(*) Invalid Input
Sleep problems or insomnia(*) Invalid Input
Spinal curvatures(*) Invalid Input
Stroke(*) Invalid Input
Swelling of ankles(*) Invalid Input
Swollen joints(*) Invalid Input
Thyroid condition(*) Invalid Input
Tuberculosis(*) Invalid Input
Ulcers(*) Invalid Input
Varicose veins(*) Invalid Input
Venereal disease(*) Invalid Input
Other medical info. Invalid Input