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New Patient Intake Form

Basic Patient Information
Name: __________________________________________ Date: _____________
Street Address: _________________________________________________________________________
City: __________________________ State: ________________ Zip: _________________
Home Phone: ___________________________ Cell Phone: ________________
Email Address: _____________________________________________________
Sex: M F Age: _______________ Birth date: _____________________________________
How tall are you? __________________ How much do you weigh? ________________________
How did you hear about us? ______________________________________________________________
Education: ____ High School _____Advanced Degree/Vocational Degree ____College Graduate
Marital Status: Single Married Widowed Separated Divorced
If married, please give spouse’s occupation: _________________________________________________
Number of kids? ___________________
Current Occupation or Last Job: ___________________________________________________________
Current Employment Status: ____Full Time _____Part Time _____Unemployed
____Homemaker _____Retired _____Student
Health and Wellness History
Primary Care Physician: ________________________ Referring Physician: ________________________
Treating what conditions? _______________________________________________________________
Medical Prescriptions: __________________________________________________________________
Over-the-Counter Medications: ___________________________________________________________
Vitamins/Minerals: _____________________________________________________________________
Herbs: _______________________________________________________________________________
Family History: ________________________________________________________________________
Previous Illnesses: _____________________________________________________________________
Known Allergies/Sensitivities: ____________________________________________________________
Surgeries: ____________________________________________________________________________
Accidents: ____________________________________________________________________________
Your signature below indicates that you understand that you are solely responsible for any treatment
rendered in this office. All services rendered to you are charged directly to you once you become a patient, and you are personally responsible for payment. This office does not accept insurance of any kind. The
services provided are not covered by insurance due to the natural, alternative approach we use here. Your signature also indicates that you authorize the staff to perform any necessary services needed during
diagnosis and treatment. I understand the above information and guarantee this form was completed
correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I provided.
Signature: ___________________________________________ Date: ___________________________

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New Patient Intake Form

Pain and Neuropathy Concerns (Part 1)
Please answer the following questions honestly so we can do our best to help you reach your goals.
Is your pain or numbness the result of an accident? ( ) Yes ( ) No
If yes, where did it occur? Circle one: Home Work Vacation Car Other
Describe what happened: _______________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Are you receiving compensation or disability payments now? ( ) Yes ( ) No
If yes, are the payments adequate? ( ) Yes ( ) No
Do you have an application for compensation or disability payments pending? ( ) Yes ( ) No
What is the main problem for which you are seeking treatment at our clinic?
_____________________________________________________________________________________
_____________________________________________________________________________________
Please describe the location of your pain and numbness:
_____________________________________________________________________________________
_____________________________________________________________________________________
How long have you had your current pain or numbness problem?
_____________________________________________________________________________________
_____________________________________________________________________________________
How did your current pain or numbness start? Was there a precipitating event?
_____________________________________________________________________________________
_____________________________________________________________________________________
How do the following affect your pain, numbness or tingling? (Please circle one for each item.)
Lying Down Decrease No Effect Increase
Standing Decrease No Effect Increase
Sitting Decrease No Effect Increase
Walking Decrease No Effect Increase
Exercise Decrease No Effect Increase
Medication Decrease No Effect Increase

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New Patient Intake Form

Pain and Neuropathy Concerns (Part 2)
Please answer the following questions honestly so we can do our best to help you reach your goals.
Please circle all of the treatments you have tried for your pain, numbness or tingling:
Hospital bed rest Traction Surgery Exercise
Nerve block or injection TENS (electrical stimulator) Physical Therapy
Psychotherapy
Which ones helped you the most? ______________________________________________
Which ones helped you the least? _______________________________________________
Have you ever been in treatment for misuse of alcohol or drugs? ____Y ____N
If yes, where and when?_______________________________________________________
Mark the areas that you are experiencing your pain, numbness or tingling. Indicate your pain or numbness type by marking with a letter or letters.
a) deep (inside)
b) superficial (on the skin)
c) constant (all the time)
d) intermittent (starts and stops)
e) aching
f) burning
g) shooting

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New Patient Intake Form

Pain and Neuropathy Concerns (Part 3)
Please answer the following questions honestly so we can do our best to help you reach your goals.
Are there other factors that make your pain, numbness or tingling
Better?_______________________________________________________________
Worse?_______________________________________________________________
Please rate your pain, numbness or tingling intensity on a scale from 0 (no pain) to 10 (excruciating, incapacitating, worst possible). Rate your pain, numbness or tingling during the past month.
Your pain, numbness at its worst _____
Your pain, numbness at its least _____
Your average pain, numbness______
Your current pain, numbness ______
How often do you have your pain, numbness or tingling?
_____Constantly (100% of the time) _____Nearly constantly (60-95% of time)
_____Intermittently (30-60% of time) _____Occasionally (less than 30% of time)
Have you ever had psychiatric, psychological, or social work evaluations or treatments for any problem,
including your current pain? ( ) Yes ( ) No
If yes, what and when?
_____________________________________________________________________________________
_____________________________________________________________________________________
Office Use Only:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
History:
_____________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________

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New Patient Intake Form

Soda	Circle ONLY one for either day or week: / Times Per DAY: 1 2 3 4 5 6 7 8 9 10 / Or / Times Per WEEK: 1 2 3 4 5 6 Or per MONTH: ______________
Cup of Brewed Coffee	Circle ONLY one for either day or week: / Times Per DAY: 1 2 3 4 5 6 7 8 9 10 / Or / Times Per WEEK: 1 2 3 4 5 6 Or per MONTH: ______________
Cup of Specialty Coffee	Circle ONLY one for either day or week: / Times Per DAY: 1 2 3 4 5 6 7 8 9 10 / Or / Times Per WEEK: 1 2 3 4 5 6 Or per MONTH: ______________
Small Bag of Chips	Circle ONLY one for either day or week: / Times Per DAY: 1 2 3 4 5 6 7 8 9 10 / Or / Times Per WEEK: 1 2 3 4 5 6 Or per MONTH: ______________
Candy Bar	Circle ONLY one for either day or week: / Times Per DAY: 1 2 3 4 5 6 7 8 9 10 / Or / Times Per WEEK: 1 2 3 4 5 6 Or per MONTH: ______________
Pack of Gum	Circle ONLY one for either day or week: / Times Per DAY: 1 2 3 4 5 6 7 8 9 10 / Or / Times Per WEEK: 1 2 3 4 5 6 Or per MONTH: ______________
Alcoholic Beverage	Circle ONLY one for either day or week: / Times Per DAY: 1 2 3 4 5 6 7 8 9 10 / Or / Times Per WEEK: 1 2 3 4 5 6 Or per MONTH: ______________
Eating Out/Lunch	Circle ONLY one for either day or week: / Times Per DAY: 1 2 3 4 5 6 7 8 9 10 / Or / Times Per WEEK: 1 2 3 4 5 6 Or per MONTH: ______________
Eating Out/Dinner	Circle ONLY one for either day or week: / Times Per DAY: 1 2 3 4 5 6 7 8 9 10 / Or / Times Per WEEK: 1 2 3 4 5 6 Or per MONTH: ______________

Frequency of Purchase
Please circle the average number of times daily OR the average number of times weekly you purchase these items.