new patient profile - vortala...bennett chiropractic clinic, llc d. mitchell davis dc new patient...

Bennett Chiropractic Clinic, LLC D. Mitchell Davis DC

New Patient Profile Today's Date __________ Title Mr. Mrs. Ms. Miss Dr. Prof. Rev.

First Name ____________ Middle Name ____________ Suffix Sr. Jr. 111 ___ LastName________________ NickName__________________ Address 1 __________________________ SSN ________

Address 2 Male Female Date of Birth /_--,/ A1 City_______ State ___ Zip A2 City ______ State Zip ____ Home Phone ( ____ Work Phone (_-l) __ - ___ Cell Phone ( ) __ Home email _________________ Work email _______________

Please circle your preferred Method of Contact above Is it OK to contact you at work? [ ] Yes [ ] No

Employment Status (Please circle) Full time Part time Student Retired Unemployed Disabled Self Employed Patient Job Title ___________________________________ Employer/School Name _________________________________ Employer/School Address ________________________________ City_______________ State_________ Zip____________

Employer/School Phone ~__ - Fax (~ __ - ___

Marital Status (Please circle) Single Married WidowlWidower Divorced Spouse First Name ________ lVIiddle Name _________ Last !\lame ________ Address 1__________________ Address 2,_______________ City State ___ Zip ____ City_______ State ___ Zip ____ Spouse Work Phone ( Cell Phone ( ) __ - ____ Spouse Date of Birth ___./__----'/___ Soc Sec #____

Patient Race [ ] White [ ] African American [ ] Asian Indian [ ] Native American/Alaskan Native [ 1 Hispanic [ ] Japanese [ ] Vietnamese [ ] Guamanian or Chamorro [ 1 Asia [ ] Chinese [ ] Filipino [ ] Native Hawaiian or Pacific Islander [ 1 Korean [ ] Samoan [ ] Other ______ [ ] I choose not to specify

Multi-racial (please check one) [ ] Yes [ ] No [ ] Unknown or choose not to specify

Ethnicity (please check one) [ ] Hispanic or Latino [ ] Not Hispanic or Latino [ ] I choose not to specify

Preferred Language (please check one) [ ] English [] Japanese [] Russian [ ] Persian [ ] Tagalog [ ] Armenian [ ] Spanish [] French [ ] German [ ] Vietnamese [ ] French Creole [ ] Hindi [ ] Chinese [] Italian [ ] Polish [ ] Portuguese [ ] Gujarati [ ] Urdu [ ] Korean [] Greek [ ] Arabic [ ] AmerSLan [ ] I choose not to specify

Verification Question (please choose only one question by circling the question, then give the answer to that question)

[ ] Name of your favorite pet? [] City you were born in? [] High School you attended? [ ] Favorite movie? [] Mother's maiden name? [] Street you grew up on? [] Make of first car? [ ] Your wedding anniversary? [] Your favorite color?

Answer~verific~ionque~ion______________________________

(If answer is not at least six characters, please choose a different question)


Patient Name ___________________Date_______________

Please tell us who referred you to this office, or how you decided to select this office. Please circle.

Family Member Attorney Internet Website Health Class

Friend Yellow Pages Billboard Brochure

Physician Newspaper Ad TV commercial Direct Mail Other_____________Employer Office Sign Radio

If you selected Family Member, Friend or Physician above, please give their name____________

Emergency Contact Name __________________ Phone ( ______

Your Family Physician, or the last doctor you saw as your family physician Dr. Name Practice Name Location_______

May we contact your family physician listed above to coordinate your care if needed? [ 1Yes [ ] No

Do you use tobacco in any form? [ ] Never [ ] Smoker [ ] Former Smoker [ ] Pipe [ ] Dip/Chew [ ] Cigar

If yes to tobacco, how often do you use tobacco? [] Daily [] Weekly [] Monthly

If yes to tobacco, what is your level of interest in quitting? 0 =No Interest, 10 = Very Interested Please Circle 0 1 2 3 4 5 6 7 8 9 10

Are you taking prescription medication as prescribed by your medical physician? Yes [ ] No [ ] Are you taking OTC (over the counter) medication on your own? Yes [ ] No [ ] Have you received a prescription for additional services from your medical provider? Yes [ ] No [ ]

Please list all current PRESCRIPTION medications, including frequency and dosage and the diagnosis.

If you are taking NO PRESCRIPTION medications, please check the box at the end of this line [ ]

1. Rx Dose Freq. Diagnosis


3. Rx Dose Freq. DiagnOSis

4. Rx Dose Freq . Diagnosis


6. Rx Dose Freq. Diagnosis 7. Rx Dose Freq. Diagnosis 8. Rx Dose Freq. Diagnosis 9. Rx Dose Freq. Diagnosis 10. Rx Dose Freq. Diagnosis 11. Rx Dose Freq. Diagnosis


List any known IVIEDICATION allergies If NO known MEDICATION allergies please check the box at the end of this line [ ]

1. ________Type Reaction _______ 3. ________Type Reaction______

2. ________Type Reaction _______ 4. ________Type Reaction______


Patient Name,______________________ Date_______________

Instructions On this history form it is very important that you complete every question. This will allow the doctor to understand your health history and provide better health care. Any unanswered questions will delay your appointment time with the doctor. If you need help answering a question, please ask for assistance. Please answer all questions truthfully and as accurately as possible. Thank You.

Please check all that apply. Check ONLY those that apply,

Medical Conditions [ ] Arthritis [ ] Cancer [ ] Diabetes [ ] Heart Disease [ ] High Blood Pressure [ ] Psychiatric Illness [ ] Skin disorder [ ] Stroke [ ] Other

Surgeries [ ] Appendectomy [ ] Heart Procedure [ ] Disc Procedure [ ] Hysterectomy [ ] Joint Replacement [ ] Laminectomy [ ] Prostate Removal [ ] Prostate Surgery Allergies [ ] Eggs [ ] Fish & Shellfish [ ] Milk or Lactose [ ] Peanuts [ ] Soy [ ] Sulfites [ ] Wheat/Gluten Social History [ ] caffeine use occasional [ ] caffeine use often [ ] chew tobacco occasional [ ] chew tobacco often [ ] drink alcohol occasional [ ] drink alcohol often [ ] exercise not at all [ ] exercise occasional [ ] exercise often [ ] have stress occasional [ ] have stress often [ ] smoke < 1 pack per day [ ] smoke> 1 pack per day [ ] wear seatbelts always [ ] wear seat belts never [ ] wear seatbelts usually Family History [ ] Arthritis (parent) [ ] Arthritis (sibling) [ ] Cancer (parent) [ ] Cancer (sibling) [ ] Cholesterol (parent) [ ] Cholesterol (sibling) [ ] Diabetes (parent) [ ] Diabetes (sibling) [ ] Heart problems [ ] Heart problems [ ] High Blood pressure [ ] High Blood Pressure

(parent) (sibling) (parent) (sibling) [ ] Psychiatric (parent) [ ] Psychiatric (sibling) [ ] Stroke (parent) [ ] Stroke (sibling) [ ] Thyroid (parent) [ 1 Thyroid (sibling) Substance Use [ ] Alcohol (past) [ ] Alcohol (present) [ ] Amphetamines (past) [ ] Amphetamines (present) [ ] Barbiturates (past) [ ] Barbiturates (present) [ ] Cocaine (past) [ ] Cocaine (present) [ ] Marijuana (past) [ ] Marijuana (present) [ ] Other (past) [ ] Other (present) __ Male Children [ 1 under 6 years [ ] under 10 years [ 1 under 19 years Female Children [ ] under 6 years [ 1 under 10 years [ ] under 19 years Occupational Activities [ ] Administration [ ] Business Owner [ ] Clerical/Secretarial [ ] Computer user [ 1 Construction [ ] Daycare/childcare [ ] Executive/Legal [ ] Food Service [ ] Healthcare [ ] Heavy equip oper [ ]Heavy manual labor [ ] Home services [ ] Household [ ] light manual labor [ ] Manufacturing [ ] Medium manual labor [ ] Military [ ] Police/Fire [ ] Professional Services [ ] Retail Worker [ ] Teacher [ ] Truck Driver Recreational Activities [ ] Backpacking [ ] Biking [ ] Boating [ ] Football [ ] Golf [ ] Racket Ball [ ] Running [ 1 Skiing ' [ ] Soccer [ ] Swimming [ ] Tennis [ ] Walking [ ] Weight Lifting [ ]Other


Have you had trouble with any of the following:

Cardiovas~ular: [ ] No to all Respiratory: [ ] No to all Allergic/immunological: [ ] No to all

Present Past No Present Past No Present Past No

Poor Circulation [ ] [ ] [ ] Asthma [ ] [ ] [ ] Hives [ ] [ ] [ ]

High Blood Pressure [ ] [ ] [ ] Tuberculosis [ ] [ ] [ ] Immune Disorder [ ] [ ] [ ] Aortic Aneurism

Heart Disease

[ ] [ ]

[ ]

[ ] [ ] [ ]

Shortness of Breath

Emphysema [ 1 [ ]

[ ]

r ] [ ] [ ]

HIV/AIDS

Allergy Shots

[ ] [ ]

[ ] [ ]

[ ] [ ]

Vascular Disease [ ] [ ] [ ] Colds/Flu [ ] [ ] [ ] Cortisone Use [ ] [ ] [ ] Heart Attack [ ] [ ] [ ] CoughlWheezing [ ] [ ] [ ] Chest Pain [ ] [ ] [ ] Gastrointestinal: [ 1 No to all

High Cholesterol [ ] [ ] [ ] Ears/Noserrhroat [ ] No to all Present Past No

Pace Maker [ ] [ J [ ] Present Past No Gall Bladder Problems [ ] [ ] [ ]

JawrrMJ Pain [ ] [ ] [ ] Dizziness [ ] [ 1 [ ] Bowel Problems [ ] [ ] [ ] Irregular Heartbeat [ ] [ ] [ ] Hearing Loss [ ] [ ] [ ] Constipation [ ] [ ] [ ] Swelling of Legs [ ] [ ] [ ] Sinus Infection [ ] [ ] [ ] Liver Problems [ ] [ ] [ ]

Nose Bleeds [ ] [ ] [ J Ulcers [ ] [ ] [ ] Genitourinary: [ ] No to all Sore Throat [ ] [ ] [ ] Diarrhea [ ] [ ] [ ]

Present Past 1\10 Difficulty Swallowing [ 1 [ ] [ ] Nausea/Vomiting [ ] [ ] [ ] Kidney Disease [ ] [ ] [ ] Bleeding Gums [ ] [ ] [ ] Bloody Stools [ ] [ ] [ ] Lower Side Pain [ ] [ ] [ ] Poor Appetite [ ] [ ] [ ]

Burning Urination [ ] [ ] [ ] Eyes: [ ] No to all

Frequent Urination [ ] [ ] [ ] Present Past No Musculoskeletal: [ ] No to all

Blood in Urine [ ] [ ] [ J Glaucoma [ ] [ ] [ ] Present Past No

Kidney Stones [ ] [ ] [ ] Double Vision [ ] [ ] [ ] Gout [ ] [ ] [ ] Blurred Vision [ J [ ] [ ] Arthritis [ ] [ ] [ ]

Hematologic/Lymphatic: [ ] No to all Joint Stiffness [ ] [ ] [ ]

Present Past No Integumentary: [ ] No to all Muscle Weakness [ ] [ ] [ J Hepatitis [ ] [ ] [ ] Present Past No OsteoporoSiS [ ] [ ] [ ]

Blood Clots [ ] [ ] [ ] Skin Lesions [ ] [ ] [ ] Broken Bones [ ] [ ] [ ]

Cancer [ ] [ ] [ ] Skin Ulcers [ ] [ ] [ ] Joint Replacement [ ] [ ] [ ] Easy Bruising [ ] [ ] [ ] Skin Disease [ ] [ ] [ ]

Easy Bleeding [ ] [ ] [ ] Eczema [ ] [ ] [ ] Endocrine: [ ] No to all

Fever/Chills/Sweats [ ] [ ] [ ] Psoriasis [ ] [ ] [ ] Present Past No

Rashes [ ] [ .] [ ] Thyroid Disease [ ] [ ] [ ]

Diabetes [ 1 [ ] [ ]

Hair Loss [ ] [ ] [ ] Menopause [ ] [ ] [ ]

Menstrual Problems [ ] [ ] [ ]

Psychiatric: [ ] No to all Constitutional: [ ] No to all Neurological: [ ] No to all

Present Past No Present Past No Present · Past No

Depression [ ] [ ] [ ] Weight Loss or Gain [ ] [ ] [ ] Babinski [ ] [ 1 [ ]

Anxiety Disorder [ ] [ ] [ ] Energy Level Problem [ ] [ ] [ ] Stroke [ ] [ ] [ ]

Unusual Stress [ ] [ ] [ ] Difficulty Sleeping [ J [ J [ ] Seizures [ ] [ J [ ] Head Injury [ ] [ ] [ J Brain Aneurysm [ ] [ ] [ ] Numbness [ ] [ ] [ ] Severe Headaches [ ] [ ] [ ]

Pinched Nerves [ ] [ ] [ ] Parkinsons Disease [ ] [ ] [ ] Carpal Tunnel [ ] [ ] [ ] SpinningIBaJance Issues [ ] [ ] [ ]


Patient Name ___________________Date_____________.

Subjective: Please mark the following drawing showing where your pain is

Please select the level of your pain TODAY o 1 2 3 4 5 6 7 8 9 10

No Pain Worst Pain Possible

Please describe the problem you would like for us to address today. _________________

When did your symptoms start? (Please give a date if possible) __________________

How did your symptoms begin? (Please describe any accident or injury), ________________

How often, per day, do you experience your symptoms? [ 1 Constantly (76-100%) [] Frequently (51-75%) [1 Occasionally (26-50%) [llntermittently (0-25%)

What describes the nature of your symptoms? [ 1 Sharp [ ] Dull Ache [ 1 Numb [ 1 Shooting [ ] Burning [ 1 Tingling

How are your symptoms changing? [ 1 Getting Better [ 1 Not changing [ 1 Getting Worse

During the past four weeks, indicate the average intensity of your symptoms o 1 2 3 4 5 6 7 8 9 10

No Pain Worst Pain Possible


Patient Name ___________________Date_______________

During the past four weeks, how much has your pain interfered with your normal job/work and household chores [ ] Not at all [] A little bit [] Moderately [] Quite a bit [] Extremely

During the past four weeks how much of the time has your condition interfered with your social activities? [ ] All the time [] Most of the time [] Some of the time [] A little of the time [] None of the time

In general would you say that your overall health right now is ... [ ] Excellent [] Very Good [] Good [] Good [] Fair [] Poor

Who else have you seen for this problem? [ ] No one [ ] Other Chiropractor [ ] Medical Doctor [ ] Physical Therapist [ ] Other __________

What treatment, if any, did you receive for your symptoms? [] None [ ] Adjustments [ ] Physical Therapy [ ] Medication [ ] Surgery [ ] Surgery [ ] Other _________

When did you receive this treatment? [ ] N/A [ ] in the last month [ ] 2-3 months ago [ ] 3-6 months ago [ ] 6 months-1 year ago [ ] 1-2 years ago [ ] 2-5 years ago [ ] 5-10 years ago [ ] More than 10 years ago G~e a spedficdateWpossible _____________________________~

What tests have you had for your symptoms? [ ] None []X-Rays []MRI []CTScan []Other _____________________~

When were these tests done? [ ] N/A [ ] In the last month [ ] 2-3 mos ago [ ] 3-6 mos ago [ ] 6 mos-1 year ago [ ] 1-2 years ago [ ] 2-5 years ago [ ] 5-10 years ago [ ] more than 10 years ago

Have you had similar symptoms in the past? [ 1Yes [ ] No

If you have received treatment in the past for the same symptoms, who did you see? [ ] No one [ ] This office [ ] Another Chiropractor [ ] Medical Doctor [ ] Physical Therapist [ ] Other _____________

What is your occupation? [ 1Professional/Executive [ ] White Collar/Secretarial [ ] Tradesperson [ 1 Skilled Laborer [ ] Unskilled Laborer [ ] Homemaker [ ] Full-Time Student [ ] Part-Time Student [ ] Retired [ ] Disabled [ ] Unemployed Other _______________________

If you are employed, are you [ ] Full-Time [ ] Part-Time [ ] Self-Employed [ ] Currently Off Work

Please select as many words to describe your pain as you need: Dull Sharp Sharp with movement Throbbing Aching Tingling Stabbing Cramping

Burning Deep Numb


Patient Name,_____________________,Date,________________

Does your pain stay in one place or radiate to another part of your body? Stays in one place [ ] or Radiatestomy__________________________~

Does your problem hurt more at any particular time of day or night? ___________________

Please select ONL Y ONE of the following activities. Please indicate how the activity affects you.

Carrying [ 1 able to carry heavy objects without pain [ 1 able to carry heavy objects but with increased pain [ 1 able to manage medium weights [ 1 able to manage light weights [ 1 unable to carry anything at all

Headaches [ 1 having no headaches [ 1 having 1 headache per month [ 1 having 2 headaches per month [ 1 having 1 headache per week [ 1 having 2 headaches per week [ 1 having 3 headaches per week [ 1 having 4-5 headaches per week [ 1 having 6-7 headaches per week [ 1 having constant headaches

Lying [ 1 able to lay as long as I want without pain [ 1 able to lay 120 min without pain [ 1 able to lay 90 min without pain [ 1 able to lay 60 min without pain [ 1 able to lay 50 min without pain [ 1 able to lay 40 min without pain [ 1 able to lay 30 min without pain [ 1 able to lay 20 min without pain [ 1 able to lay 10 min without pain

Reading [ 1 able to read as much as I like without pain [ 1 able to read as much as I want with slight pain [ 1 able to read as much as I want with moderate pain [ 1 able to read but not as much as I would like due to pain [ 1 able to read only a little due to severe pain [ 1 unable to read at all due to pain

Driving [ 1 able to drive as long as I need without pain [ 1 able to drive 120 minutes without pain [ 1 able to drive 90 minutes without pain [ 1 able to drive 60 minutes without pain [ 1 able to drive 45 minutes without pain [ 1 able to drive 30 minutes without pain [ 1 able to drive 20 minutes without pain [ 1 able to drive 10 minutes without pain [ 1 unable to drive due to pain

House work [ 1 able to do 90 min without pain [ 1 able to do 80 min without pain [ 1 able to do 70 min without pain [ 1 able to do 60 min without pain [ 1 able to do 50 min without pain [ 1 able to do 40 min without pain [ 1 able to do 30 min without pain [ 1 able to do 20 min without pain [ 1 able to do 10 min without pain [ 1 unable to do any housework due to pain

Personal Care [ 1 able to do without causing extra pain [ 1 able to do but causes increased pain [ 1 able to do slowly and carefully [ 1 able to do with some help [ 1 able to do with assistance

Recreation [ 1 able to engage in all activities without pain [ 1 able to engage in all activities but with pain [ 1 able to engage in some but not all activities [ 1 able to engage in only a few activities [ 1 able to engage in very few activities [ 1 unable to engage in any activities


Patient Name,___________________Date___________________

Running [ 1 able to run as far as I like without pain [ 1 able to run 1 % miles without pain [ 1 able to run 1 mile without pain [ 1 able to run % mile without pain [ 1 able to run % mile without pain [ 1 unable to run at all without pain

Sit to stand(getting up out of a chair) [ 1 able to get out of high chair without pain [ 1 able to get out of medium height chair without pain [ 1 able to get out of low chair without pain [ 1 able to get out of recliner without pain [ 1 able to get out of any chair without pain [ 1 unable to get out of any chair without pain [ 1 unable to get out of any chair without assistance

Sitting [ 1 able to sit as long as I like without pain [ 1 able to sit 8 hours without pain [ 1 able to sit 7 hours without pain [ 1 able to sit 6 hours without pain [ 1 able to sit 5 hours without pain [ 1 able to sit 4 hours without pain [ 1 able to sit 3 hours without pain [ 1 able to sit 2 hours without pain [ 1 able to sit 1 hour without pain [ 1 unable to sit at all due to pain

Standing [ 1 able to stand as long as I want without pain [ 1 able to stand 60 min without pain [ 1 able to stand 45 min without pain [ 1 able to stand 30 min without pain [ 1 able to stand 20 min without pain [ 1 able to stand 10 min without pain [ 1 able to stand 5 min without pain [ 1 unable to stand at all without pain

Shopping [ 1 able to shop as long as I want without pain [ 1 able to shop 2 or more hours without pain [ 1 able to shop 1 % hours without pain [ 1 able to shop 1 hour without pain [ 1 able to shop 50 min without pain [ 1 able to shop 40 min without pain [ 1 able to shop 30 min without pain [ 1 able to shop 20 min without pain [ 1 able to shop 10 min without pain [ 1 unable to shop at all without pain

Sleeping [ 1 able to sleep through the night without pain [ 1 slightly disturbed sleep{loss of less than 1 hour of sleep) [ 1 mildly disturbed sleep(loss of 1-2 hours of sleep) [ 1 moderately disturbed sleep(loss of 2-3 hours of sleep) [ 1 severely disturbed sleep(loss of 3-5 hours sleep) [ 1 completely disturbed sleep{loss of 5-7 hours sleep)

Walking [ 1 able to walk a far as I like without pain [ 1 able to walk 1 or more miles without pain [ 1 able to walk % mile without pain [ 1 able to walk 1 block without pain [ 1 able to walk 100 feet without pain [ 1 able to walk 50 feet without pain [ 1 able to walk 10 feet without pain [ 1 unable to walk at all without pain

Signature________________________ Date___________

Thank You for completing these forms accurately. Please return them to the person who gave them to you.

new patient profile - vortala...bennett chiropractic clinic, llc d. mitchell davis dc new patient...

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