New Patient Health Information Form Step 1 of 7 14% Patient InformationDate: MM slash DD slash YYYY Patient Last Name First Name MI Address Street Address City State / Province / Region ZIP / Postal Code Email Sex M F Age Birthdate MM slash DD slash YYYY Height Weight Patient Married Widowed Single Minor Separated Divorced Partnered Years Occupation Patient Employer/School Employer/School Address, Employer/School Phone Line Spouse's Name Birthdate Spouse's Employer Whom may we thank for referring you? Insurance InformationWhat you hoping to achieve here at Ascent Health? Phone NumbersHomeCellBest time and place to reach you,IN CASE OF EMERGENCY, CONTACTName Relationship Home LineWork LineAccident InformationIs condition due to an accident Yes No Date of accident MM slash DD slash YYYY Type of accident auto work home other Other To whom have you made a report of your accident? auto insurance employer work comp Other Attorney name (if applicable). Other Patient ConditionReason for Visit When did your symptoms appear? Is this condition getting progressively worse? Yes No Unknown Rate severity of your pain on a scale from 1 (least pain) to 10 (severe pain) Type of Pain Sharp Dull Throbbing Numbness Aching Shooting Burning Tingling Cramps Stiffness Swelling Other Other How often do you have this pain Is it constant or does it come and go? Does it interfere with your work sleep daily routine recreation Activities or movements that are painful to perform sitting standing walking bending lying Health HistoryWhat treatment have you already received for your condition? Surgery Physical Therapy Chiropractic Services None Other Name and address of other doctor(s) who have treated you for your conditionOther Date of Last Exams Physical Exam MM slash DD slash YYYY Spinal X-ray MM slash DD slash YYYY Blood Test MM slash DD slash YYYY Spinal Exam MM slash DD slash YYYY Chest X-Ray MM slash DD slash YYYY Urine Test MM slash DD slash YYYY Dental X-Ray MM slash DD slash YYYY MRI, OT-Scan, Bone Scan MM slash DD slash YYYY Place a mark on "Yes" or "No" to indicate if you have had any of the following:AIDS/HIV Yes No Glaucoma Yes No Pneumonia Yes No Alcoholism Yes No Goiter Yes No Polio Yes No Allergy Shots Yes No Gout Yes No Prostate Problem Yes No Anemia Yes No Heart Disease Yes No Prosthesis Yes No Anorexia Yes No Hepatitis Yes No Psychiatric Care Yes No Appendicitis Yes No Herniated Disk Yes No Rheumatoid Arthritis Yes No Arthritis Yes No Herpes Yes No Rheumatic Fever Yes No Asthma Yes No High Cholesterol Yes No Scarlet Yes No Bleeding Disorders Yes No Kidney Disease Yes No Stroke Yes No Breast Lump Yes No Liver Disease Yes No Suicide Attempt Yes No Bronchitis Yes No Measles Yes No Thyroid Problems Yes No Bulimia Yes No Migraines Yes No Tonsillitis Yes No Cancer Yes No Miscarriage Yes No Tuberculosis Yes No Cataracts Yes No Mononucleosis Yes No Tumors, Growths Yes No Chemical Dependency Yes No Multiple Sclerosis Yes No Typhoid Fever Yes No Chicken Pox Yes No Mumps Yes No Ulcers Yes No Diabetes Yes No Osteoporosis Yes No Vaginal Infections Yes No Emphysema Yes No Pacemaker Yes No Venereal Disease Yes No Epilepsy Yes No Parkinson's Disease Yes No Whooping Cough Yes No Fractures Yes No Pinched Nerves Yes No Other Yes No Exercise None Moderate Daily Heavy Work Activity Sitting Standing Light Labor Heavy Labor Habits Smoking Alcohol Coffee/Caffeine Drinks High Stress Level Packs per Day Drinks per Week Cups per Day Reason Are you pregnant? Yes No Date: MM slash DD slash YYYY Injuries/Surgeries you have hadFalls Head Injuries Broken Bones Dislocations Surgeries Medications MedicationsPharmacy Pharmacy PhoneAllergiesAllergiesVitamins/Herbs/MineralsVitamins/Herbs/Minerals
