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Patient Forms

Schedule Your Chiropractic Appointment in Elizabethtown, PA

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Patient Forms

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- Step 1 of 6

How did you hear about us? *

Family
Friend
Co-Worker
Close to home/work
Dr.
Yellow Pages
Drove by
Hospital
Insurance Plan

Personal Information

Title *

Mr.
Ms.
Mrs.

Name *

First

Last

Suffix

Jr
Sr
II
III

Birth Date *

Age *

Sex *

Male
Female

SSN

Marital Status *

Single
Married
Widowed
Divorced
Separated

Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Home Phone

Work Phone

Cell Phone *

Fax #

Email Address *

Spouses Name

Emergency Contact

Name *

First

Middle

Last

Relationship *

Spouse
Relative
Friend
Other

Other *

Home Phone

Cell Phone *

Work Phone

Employment Information

Business Name *

Employer’s Email Address *

Phone *

Fax #

Occupation/Job Title

Job Description

Current Health Condition

Unwanted Condition *

When did this Condition BEGIN? *

Has it ever occurred before? *

Yes
No

When?

Is the Condition *

Auto Related
Job Related
Home Injury
Slip or Fal
Lifting
Slept Wrong
Unknown Cause
Other

Explain

Date of Accident *

Time of Accident *

Condition/Pain STARTED on what Date

Do you SUFFER with ANY OTHER Condition than which you are now consulting us?

Name did When?

REVIEW OF SYSTEMS

Below is a list of symptoms that may seem unrelated to the purpose of your appointment.

Constitutional *

I DENY having or have had any of the symptoms or problems listed below.

Checkboxes *

chills
fatigue
night sweats
weight loss
daytime drowsiness
fever
weight gain

Eyes/Vision *

I DENY having any of the symptoms or problems listed below.

Checkboxes *

blindness
change in vision
field cuts
photophobia
blurred vision
double vision
glaucoma
tearing
cataracts
eye pain
itching
wear glasses/contacts

Ears, Nose and Throat *

I DENY having any of the symptoms or problems listed below.

Checkboxes *

bleeding
ear drainage
hearing loss
nosebleeds
sore throat
dentures
ear pain
history of head injury
postnasal drip
tinnitus
difficulty swallowing
fainting
hoarseness
rhinorrhea (runny nose)
TMJ problems
discharge
frequent sore throats
loss of sense of smell
sinus infections
dizziness
headaches
nasal congestion
snoring

Respiration *

I DENY having any of the symptoms or problems listed below

Checkboxes *

asthma
coughing up blood
sputum production
cough
shortness of breath
wheezing

Cardiovascular *

I DENY having any of the symptoms or problems listed below.

Checkboxes *

angina (chest pain or discomfort)
high blood pressure
shortness of breath with exertion or exercise
chest pain
low blood pressure
swelling of legs
claudication (leg pain/ache)
orthopnea (difficulty breathing lying down)
ulcers
heart murmur
palpitations
varicose veins
heart problems
paroxysmal nocturnal dyspnea (waking at night w/ shortness of breath)

Gastrointestinal *

I DENY having any of the symptoms or problems listed below.

Checkboxes *

abdominal pain
diarrhea
indigestion
abnormal stool
vomiting blood
belching
difficulty swallowing
jaundice
abnormal stool color
black - tarry stools
heartburn
nausea
abnormal stool consistency
constipation
hemorrhoids
rectal bleeding
vomiting

Female *

I DENY having any of the symptoms/problems and/or using any of the items listed below.

Checkboxes *

birth control
cramps
irregular menstruation
vaginal bleeding
breast lumps/pain
frequent urination
pregnancy
vaginal discharge
burning urination
hormone therapy
urine retention

Male *

I DENY having any of the symptoms or problems listed below.

Checkboxes *

burning urination
frequent urination
prostate problems
erectile dysfunction
hesitancy/ dribbling
urine retention

Endocrine *

I DENY having any of the symptoms or problems listed below.

Checkboxes *

cold intolerance
excessive hunger
goiter
unusual hair growth
diabetes
excessive thirst
hair loss
voice changes
excessive appetite
abnormal frequency of urination
heat intolerance

Skin *

I DENY having any of the symptoms or problems listed below.

Checkboxes *

changes in nail texture
hair loss
itching
skin lesions / ulcers
changes in skin color
hives
paresthesias
varicosities
hair growth
history of skin disorders
rash

Nervous System *

I DENY having any of the symptoms or problems listed below.

Checkboxes *

dizziness
limb weakness
numbness
slurred speech
tremor
facial weakness
loss of consciousness
seizures
stress
unsteadiness of gait/ loss of balance
headache
loss of memory
sleep disturbance
strokes

Psychologic *

I DENY having any of the symptoms or problems listed below.

Checkboxes *

anhedonia
behavioral change
convulsions
memory loss
anxiety
bi-polar disorder
depression
mood change
loss or change in appetite
confusion
insomnia

Allergy *

I DENY having any of the symptoms or problems listed below.

Checkboxes *

anaphalaxis
itching
chronic nasal congestion
sneezing
food intolerance
acute nasal congestion
rash

Hematologic *

I DENY having any of the symptoms or problems listed below.

Checkboxes *

anemia
blood clotting
bruising easily
lymph node swelling
bleeding
blood transfusion
fatigue

PAST HEALTH HISTORY

Fill out carefully as these problems can affect your overall course of care.

Previous Care for Same Condition *

I have not seen a doctor for this condition OR Fill in the information BELOW

Have you seen other doctors for THIS CONDITION?

Yes
No

Type of Treatment

Was the treatment beneficial in resolving condition?

Yes
No

If yes, Who? (Name)

Explain

Previous Chiropractic Care *

I have not previously seen a Chiropractor OR Fill in the information BELOW

Doctor’s Name

Location

Date of Last Visit

Current Medication (s)

List ANY/ALL medications you are CURRENTLY taking. Be Specific.

Medication

Dosage

For What Condition?

How long have you been taking this?

Childhood Illness (es)

LIST all health conditions. CIRCLE all CURRENT conditions.

Your trusted chiropractor in Elizabethtown, PA, offering expert spinal adjustments, back pain relief, sciatica treatment, and wellness-based chiropractic care for families throughout Central PA.

Services

Back Pain Treatment
Neck Pain Relief
Headache & Migraine Care
Sciatica Treatment
Pelvic & Postural Correction

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