New Patient Applied Kinesiology FormPERSONAL HISTORYDate(Required) MM slash DD slash YYYY Name(Required) First Last Address(Required) Street Address City State / Province / Region ZIP / Postal Code Email Primary Phone(Required)Work/Cell PhoneBirth Date(Required) Month Day YearAge(Required)Sex(Required) M FHeight(Required)Feet and InchesWeight(Required)PoundsCheck One(Required) Married Single Widowed Divorced SeparatedNo. of ChildrenEmployerType of WorkReferred to this office byEmergency Contact(Required)NameEmergency Contact Phone(Required)Who is responsible for your bill? You and:(Required) Spouse Worker’s Compensation Medicare Auto Insurance Personal Health Insurance OtherIf you selected 'Other' above, please specify:CURRENT HEALTH CONDITIONPurpose of this appointment/major complaint(Required)Other doctors seen for this conditionWhen did this condition begin?Are there others in your family with this same condition?If disabled from work, please give datesChoose One (if applicable) Job Related Auto RelatedDate of accident/injuryPAST HEALTH CONDITIONMajor Surgery/Operations Appendix Tonsils Gall Bladder Hernia Heart Back Neck Leg OtherIf you selected 'Other' above, please specify:Major accidents or fallsHospitalization (Other than above)Previous Chiropractic Care(Include Doctor’s name and approximate date of last visit)Have you been treated for any health conditions in the last year? Yes NoIf yes, please explainDoes anyone else in your family have the same or similar condition?Please select any of the following signs and symptoms that apply.Below is a list of conditions which may seem unrelated to the purpose of your appointment. However, these questions must be answered carefully as these problems can affect your overall diagnosis, treatment plan and possibility of being accepted for care. A complete history and understanding of your health status will facilitate care.General Symptoms Headaches Fever Chills Night Sweats Fainting Dizziness Convulsions Loss of Sleep Fatigue Nervousness Loss of Weight Numbness or Pain in Arms/Legs/Hands Allergy Wheezing NeuralgiaGastro-Intestinal Poor Appetite Poor Digestion Excessive Hunger Belching or Gas Nausea Vomiting Vomiting Blood Pain Over Stomach Constipation Diarrhea Colon Trouble Hemorrhoids-Piles Liver Trouble Jaundice Gall Bladder TroubleEar Nose Throat Deafness Earache Ear Noises Ear Discharges Nasal Obstruction Nosebleeds Sore Throat Hoarseness Hay Fever Asthma Frequent Colds Enlarged Thyroid Tonsillitis Sinus TroubleGenito-Urinary Frequent Urination Painful Urination Blood in Urine Kidney Infection Bed Wetting Inability to Control Urine Prostate TroubleMuscles & Joints Weakness Twitching Stick Neck Backache Swollen Joints Tremors Foot Troubles Painful Tail Bone Pain Between Shoulders Hernia Spinal CurvatureCardio-Vascular Rapid Heart Slow Heart High Blood Pressure Low Blood Pressure Pain Over Heart Previous Heart Trouble Swelling of Ankles Poor Circulation Varicose Veins StrokesSkin or Allergies Skin Eruptions Itching Bruising Easily Dryness Boils Sensitive Skin Hive or Allergy Eczema MedicinesEye Poor Vision Crossed Eyes Pain in EyesRespiratory Chronic Cough Spitting Blood Spitting Phlegm Chest Pain Difficulty BreathingSmoking Status Every Day Smoker Occasional Smoker Former Smoker Never SmokedIf you selected 'Smoker' above, how many packs per day?Do you drink alcohol?Enter Y/N and glasses/day (if applicable)Do you drink coffee?Enter Y/N and cups/day (if applicable)Exercise None Moderate DailyFor Women Only Painful Periods Excessive Flow Irregular Cycles Hot Flashes Cramps or Backache Miscarriage Vaginal Discharge Pregnant at this timeDate of Last Pap/By WhomFAMILY HISTORYMOTHER Diabetes Heart Kidney Cancer Back/Spine/Neck PainsFATHER Diabetes Heart Kidney Cancer Back/Spine/Neck PainsBROTHERS Diabetes Heart Kidney Cancer Back/Spine/Neck PainsSISTERS Diabetes Heart Kidney Cancer Back/Spine/Neck PainsHave you had any of the following diseases? Appendicitis Pneumonia Rheumatic Fever Polio Tuberculosis Whooping Cough Anemia Measles Mumps Chicken Pox Diabetes Cancer Heart Disease Goiter Influenza Pleurisy Alcoholism Venereal Infection Arthritis Epilepsy Mental Disorder Lumbago EczemaAre you currently taking any medications? (Please include regularly used over the counter medications.)Enter ‘Medication Name: Dosage – Frequency’ (i.e. 5mg once a day, etc.)Do you have any medication allergies?Enter ‘Medication Name: Reaction (Onset Date) – Additional Comments’Why Chiropractic?People go to chiropractors for a variety of reasons. Some go for symptomatic relief of pain or discomfort (Relief Care). Other are interested in having the cause of the problem as well as the symptoms corrected and relieved (Corrective Care). Still other want whatever is malfunctioning in their bodies brought to the highest state of health possible with chiropractic care (Comprehensive Care). You doctor will weigh your needs and desires when recommending your treatment program.Please check the type of care desired so that we may be guided by your wishes whenever possible. Relief Care Corrective Care Comprehensive Care Check here is you would like the doctor to select the type of care appropriate for your condition.If this is an auto accident-related injury, please complete the Auto Accident Form. Thank you!METABOLIC ASSESSMENT FORM™Name(Required) First Last Age(Required)Sex(Required) M FDate(Required) MM slash DD slash YYYY PART IPlease list your 5 major health concerns in order of importance: Add RemovePART IIPlease select the appropriate number on all questions below. 0=Least/Never 3=Most/AlwaysCategory IFeeling that bowel do not completely empty 0 1 2 3Lower abdominal pain relieved by passing stool or gas 0 1 2 3Alternating constipation and diarrhea 0 1 2 3Diarrhea 0 1 2 3Constipation 0 1 2 3Hard, dry, small stool 0 1 2 3Coated tongue or "fuzzy" debris on tongue 0 1 2 3Pass large amount of foul-smelling gas 0 1 2 3More than 3 bowel movements daily 0 1 2 3Use laxatives frequently 0 1 2 3Category IICANCELLATION POLICY(Required)Atrium Health Services is dedicated to providing all of our patients with exceptional care. In order to ensure prompt and available appointments for all, we require a 24-hour notice for any change or cancellation of your appointment to avoid a broken appointment charge. Please check the box acknowledging that you have read and understand our cancellation policy. I agree to the cancellation policy.
