New Patient Form Today’s Date:_______________ __ ______________ __________( / / )_______ ________________________________ Name Date of Birth Street Address Unit City State Zip __________________________________________________________________________________________________ Cell Phone Carrier (for appt reminder texts) Home Phone Email If you prefer not to reCeive text message appointment reminders, please check here: Opt-out of Text Message Reminders Gender Male Female Employer & OcCupation ___________________________________________________ How did you find us and who Can we thank for referring you? ______________________________________________ Have you ever seen a Chiropractor? □ Yes □ No Acupuncturist? □ Yes □ No Nutritionist? □ Yes □ No Would you like to learn aBout Acupuncture? □ Yes □ No Functional Medicine & Clinical Nutrition? □ Yes □ No What are your treatment goals? (anything important to you, eg “I want to be pain free“ or “I want to run a faster raCe”) __________________________________________________________________________________________________ __________________________________________________________________________________________________ Patient Symptoms Is the reason for your visit related to: □Auto Accident □Work Injury □Neither Briefly describe your symptoms: _________________________________________________________________________ ______________________________________________________________________________________________________ When did your symptoms begin? ________________________ (estimated date or event) How did your symptoms begin? __________________________________________________________________________ What, if anything, helps to relieve your symptoms: __________________________________________________________ ______________________________________________________________________________________________________ Do you notice any patterns in your symptoms (e.g. worse at night): ____________________________________________ ______________________________________________________________________________________________________ Des cribe the frequency of your s ymptoms : (check one) In general, would you say your overall health right now is…(check one) Constant (76%-100% of waking time) Excellent Frequent (51%-75% of waking time) Very good Occasional (26%-50% of waking time) Good Intermittent (0%-25% of waking time) Fair Poor How much have your symptoms interfered with your What activities are limited by your s ymptoms ? (check one or more) daily activities (including both work outside the home Standing Walking and hous ework)? (check one) Sitting Running Not a t a ll Lying down Working out A little b it Sleeping Mo ve m e n t Moderately Lifting Bowel movements Quite a bit Des k work Bending Extremely Other: _____________________________ (please continue to next page) Office Use Only: O P Q R S T / S I Q O R A A A Staff Use ☐ Sign In ☐ Photo ☐ Releases ☐ Ref SourCe PostVisit:☐ Demo ☐ Ins. ☐ Release Dates ☐ NPE Date ☐ MD Log www.alignedmodernhealth.com Page 1 Rate your average pain intensity for your primary symptom (circle a number) Last 24 hours: no pain 0 1 2 3 4 5 6 7 8 9 10 worst pain Past week: no pain 0 1 2 3 4 5 6 7 8 9 10 worst pain Symptom Map Step 1: Number each painful Step 2: Fill in the body part Step 3: Check the boxes Step 4: Rate the severity area on the diagram below corresponding to each number that describe each pain of each pain 0 = No Pain or Discomfort 10 = Severe Pain Sharp Dull ache Stabbing Stiffness Spasm Throbbing Burning Example L R Shoulder X X X 0 1 2 3 4 5 6 7 8 9 10 1 L R 0 1 2 3 4 5 6 7 8 9 10 2 L R 0 1 2 3 4 5 6 7 8 9 10 3 L R 0 1 2 3 4 5 6 7 8 9 10 4 L R 0 1 2 3 4 5 6 7 8 9 10 5 L R 0 1 2 3 4 5 6 7 8 9 10 Headaches: Yes No 0 1 2 3 4 5 6 7 8 9 10 Medical History Where applicable, specify the approximate date of your most recent: (month / year) Physical Exam: / None Why? ______________________________________ Dental X-rays: / None Why? ______________________________________ Spinal X-ray / None Why? ______________________________________ MRI: / None Why? ______________________________________ Other Imaging: __ / None Why? ______________________________________ List any medications you take: ___________________________________________________________________________ Describe any specific diets you follow: ____________________________________________________________________ Have / do you… Yes No If yes, please provide a brief explanation …been hospitalized in the past 5 years? ______________________________________________________ ...had any surgeries? ______________________________________________________ ...had any emotional/stress disorders? ______________________________________________________ ...had any broken bones? ______________________________________________________ …had any strains or pains? ______________________________________________________ …ever used foot orthotics? ______________________________________________________ …take minerals, herbs or vitamins? ______________________________________________________ What are your work duties? ______________________________________________________________________________ How is most of your day spent? Standing Sitting Other: __________________________________________ (please continue to next page) Office Use Only: O P Q R S T / S I Q O R A A A www.alignedmodernhealth.com Page 2 Do you have or have you previously had any of the Following symptoms: General Yes No Gastrointestinal Yes No Cardiovascular Yes No Allergies □ □ Abdominal pain □ □ Heart disease □ □ Depression/Anxiety □ □ Bloody stool □ □ High Cholesterol □ □ DiZZiness □ □ Colitis/Crohn’s □ □ High blood pressure □ □ Fainting □ □ Constipation □ □ Low blood pressure □ □ Fatigue □ □ Diarrhea □ □ ArteriosClerosis □ □ HeadaChes □ □ Heart burn □ □ Irregular pulse □ □ Loss of sleep □ □ Appetite Change □ □ Pain over heart □ □ Tremors □ □ Hernia □ □ Poor CirCulation □ □ Weight Change □ □ Liver trouble □ □ Change in heart beat □ □ SeiZures □ □ Nausea □ □ Swelling of ankles □ □ Memory Loss □ □ Vomiting Respiratory Yes No Muscle/Joint Yes No Ear Eye Nose Throat Yes No Asthma □ □ Arthritis □ □ Impaired hearing □ □ Chest pain □ □ Bursitis □ □ Ear aches □ □ ChroniC Cough □ □ Foot trouble □ □ Ringing in ears □ □ DiffiCulty breathing □ □ MusCle weakness □ □ Sinus infeCtion □ □ Shortness of breath □ □ Low baCk pain □ □ Sore throat □ □ Spitting up blood □ □ Mid baCk pain □ □ Vision problems □ □ NeCk pain □ □ Frequent Colds □ □ Other Conditions Yes No Joint pain □ □ Stuffiness □ □ Anemia □ □ Numbness □ □ Nose bleeds □ □ Cancer □ □ Tingling □ □ Diabetes □ □ Genitourinary Yes No Edema □ □ Skin Yes No Bladder infeCtion □ □ Epilepsy □ □ Bruise easily □ □ Blood in urine □ □ Gout □ □ Hives □ □ Kidney infection □ □ HIV/AIDS □ □ Rash □ □ Kidney stone □ □ Multiple sClerosis □ □ VariCose veins □ □ Prostate trouble □ □ Pace maker □ □ Acne or boils □ □ Urination Stroke □ □ ItChing □ □ Overnight > twiCe □ □ Osteoporosis □ □ EcZema □ □ >8x in 24 hours □ □ Thyroid disease □ □ InfeCtions □ □ DeCreased flow □ □ Any other Conditions? Painful urination □ □ __________________ UrgenCy to urinate □ □ __________________ WOMEN ONLY Yes No Yes No Uterine cysts □ □ Are you pregnant? □ □ Date of last PAP exam: __________________ Hot flashes □ □ If yes, how many months ___________ Date of last mammogram: _______________ Lumps in breasts □ □ Birth control? □ □ □ Normal □ Abnormal Menopause □ □ If yes, method: _____________________ Menstrual flow □ Reg □ Irreg □ Pain Prior miscarriage □ □ # of children you have: _______________ Date of last period: ____________________ (please continue to next page) Office Use Only: www.alignedmodernhealth.com Page 3 Family History Have any oF your relatives (mother, Father, siBlings, grandparents, aunts, uncles) had any of the following: Yes No If yes, please list which relative(s): Yes No If yes, please list which relative(s): AlCoholism □ □ ___________________________ Epilepsy □ □ __________________________ Anemia □ □ ___________________________ GlauComa □ □ __________________________ ArteriosClerosis □ □ ___________________________ Heart disease □ □ __________________________ Arthritis □ □ ___________________________ High blood pressure □ □ __________________________ Asthma □ □ ___________________________ High Cholesterol □ □ __________________________ Blood disorders □ □ ___________________________ Multiple sClerosis □ □ __________________________ Cancer □ □ ___________________________ Osteoporosis □ □ __________________________ Diabetes □ □ ___________________________ Stroke □ □ __________________________ Emphysema □ □ ___________________________ Thyroid disease □ □ __________________________ Lifestyle □ Single □ Married □ DivorCed □ Opposite Sex Spouse/DomestiC Partner □ Same Sex Spouse/DomestiC Partner Please descriBe your haBits regarding the Following OfFice Use Only HaBits None Light Moderate Heavy AlCohol □ □ □ □ Caffeine □ □ □ □ TobacCo □ □ □ □ Drug use □ □ □ □ ExerCise □ □ □ □ Water intake □ □ □ □ Sugar intake □ □ □ □ Other Do you have any other health issues or concerns that our staFF should Be made aware oF? _________________________________________________________________________________________________ Other Doctors Primary Care Physician: _______________________________ Hospital or AssoCiated Group: ___________________________________________________________________ Address, Phone, and Fax (if known): ______________________________________________________________ Did your primary care physician refer you to us: □Yes □No Please list any other