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Home
About Us
- Meet the Doctor
- Virtual Office Tour
Contact Us
- Appointment Request
New Patients
Services
Conditions Treated
Testimonials
COVID-19
Blog

(859) 266-1999

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New Patients

New Patient Health History Form

New Patient Health History Form

Name*

Preferred Name (Nick Name)

Address

Apt#

City

State

Zip

Marital Status

Married Single Divorced Domestic Partner Widowed

Home Phone *

Work

Cell Phone

Email Address *

Occupation

Employer

Date of Birth

Social Security #

Gender

Male Female

Were You Referred To Our Office

If Yes, Please List Name(s)

Primary Care Doctor’s Name

Other Doctors

Prefered Language

English Spanish

Other

Race/Ethnicity

Are you covered by Health Insurance?

No Yes

If so, by what carrier?

If any sections below are left blank, “NONE” will be the default answer

List any Allergies

Animals Aspirin Bees Chocolate Dairy Dust Eggs Latex Molds Penicillin Ragweed/Pollen Rubber Seasonal Allergies Shellfish Soaps Wheat X-Ray Dye None

Other

List any Surgeries

Back Brain Elbow Foot Hip Knee Neck Neurological Shoulder Wrist None

Other

List All Past Medical History conditions for YOURSELF (not family members)

Ankle Pain Arm Pain Arthritis Asthma Back Pain Broken Bones Cancer Chest Pain Depression Diabetes Dizziness Elbow Pain Epilepsy Eye/Vision Problems Fainting Fatigue Foot Pain Genetic Spinal Condition Hand Pain Headaches Hearing Problems Hepatitis High Blood Pressure Hip Pain HIV Jaw Pain Joint Stiffness Knee Pain Leg Pain Menstrual Problems Mid-Back Pain Minor Heart Problem Multiple Sclerosis Neck Pain Neurological Problems Pacemaker Parkinson's Polio Prostate Problems Shoulder Pain Significant Weight Change Spinal Cord Injury Sprain/Strain Stroke/Heart Attack

Other

List Type of Medications you are taking

NONE Anxiety Muscle Relaxors Pain Killers Insulin Birth control Cardiovascular Allergy Seizure Other

PLEASE LIST THE NAME OF ALL MEDICATIONS & THE CONDITION THEY TREAT

List your Family History

Arthritis Asthma Back Pain Cancer Depression Diabetes Epilepsy Genetic Spinal Condition High Blood Pressure Heart Problems Multiple Sclerosis Neurological Problems Parkinson's Polio Prostate Problems Stroke/Heart Attack

Please list all family members who had/has any of the problems above

Have you had chiropractic care in the past?

No Yes

Chiropractor's Name

For what condition(s) were you treated

Where X-rays taken?

No Yes

Approximately how long ago was your last adjustment?

Have you had any auto or other accidents?

No Yes

If Yes - how long ago?

Describe

SOCIAL HISTORY:

Date of last physical examination

Do you smoke?

No Yes

if NO-Have you EVER been a smoker?

I No Yes If YES-How many per day?

Do you drink alcohol?

No Yes

How many per day?

Do you drink caffeine?

No Yes

How many per day?

Do you exercise?

No Yes

What form(s)

How many days per week

Are you pregnant?

No Yes

If Yes, how many weeks?

Anticipated due date?

Main reason for consulting the office:

Become pain free Explanation of my condition Learn how to care for my condition Reduce symptoms Resume normal activity level

PATIENT COMPLAINTS – PLEASE LIST ONE COMPLAINT PER SECTION

What is your PRIMARY complaint? PLEASE LIST ONE COMPLAINT PER SECTION

Date problem began?

How did this problem begin (falling, lifting, etc.)?

How is your condition changing?

Getting Better Getting Worse Not Changing

Have you had this condition in the past?

Yes No

How often do you experience your symptoms?

Constantly (76-100% of the day) Occasionally (26-50% of the day) Frequently (51-75% of the day) Intermittently (0-25% of the day)

Describe the nature of your symptoms

Sharp Dull Numb Shooting Burning Tingling Radiating Pain Tightness Stabbing Throbbing

Other

Please rate your pain on a scale of 1 to 10 (0= no pain and 10= excruciating pain)

1 2 3 4 5 6 7 8 9 10

What activities aggravate your condition (working, exercise, etc)?

What makes your pain better (ice, heat, massage, etc)?

What is your SECOND complaint?

Date problem began?

How did this problem begin (falling, lifting, etc.)?

How is your condition changing?

GETTING BETTER GETTING WORSE NOT CHANGING

Have you had this condition in the past?

Yes No

How often do you experience your symptoms?

Constantly (76-100% of the day) Frequently (51-75% of the day) Occasionally (26-50% of the day) Intermittently (0-25% of the day)

Describe the nature of your symptoms

Sharp Dull Numb Burning Shooting Tingling Radiating Pain Tightness Stabbing Throbbing

Other

Please rate your pain on a scale of 1 to 10 (0= no pain and 10= excruciating pain)

1 2 3 4 5 6 7 8 9 10

What activities aggravate your condition (working, exercise, etc)?

What makes your pain better (ice, heat, massage, etc)?

What is your next complaint?

Date problem began?

How did this problem begin (falling, lifting, etc.)?

How is your condition changing?

GETTING BETTER GETTING WORSE NOT CHANGING

Have you had this condition in the past?

Yes No

How often do you experience your symptoms?

Constantly (76-100% of the day) Frequently (51-75% of the day) Occasionally (26-50% of the day) Intermittently (0-25% of the day)

Describe the nature of your symptoms

Sharp Dull Numb Burning Shooting Tingling Radiating Pain Tightness Stabbing Throbbing

Other

Please rate your pain on a scale of 1 to 10 (0= no pain and 10= excruciating pain)

1 2 3 4 5 6 7 8 9 10

What activities aggravate your condition (working, exercise, etc)?

What makes your pain better (ice, heat, massage, etc)?

Patient’s/Guardian’s Signature

Date

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

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Locations

--mi

Address

2505 Larkin Rd #202
Lexington, KY 40503, US

Contact Information (859) 266-1999

(859) 269-2533

[email protected]

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