New patient forms
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This registration form collects personal and contact information from patients of Shea Family Chiropractic, including name, address, phone numbers, emergency contact, and reason for visit. It also includes a health history form asking about current and past medical conditions, surgeries, injuries, medications, and lifestyle factors like exercise, smoking, and stress levels. Patients authorize the doctor to examine them and perform diagnostic tests to evaluate for vertebral subluxation.
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New patient forms
- 1. REGISTRATION FORM SHEA FAMILY CHIROPRACTIC 858-312-5066 10720 THORNMINT ROAD SUITE B, SAN DIEGO CA 92127 PERSONAL INFORMATION LAST NAME: ________________________________________________________________________ FIRST NAME: ___________________________________________________ MI: _________________ GENDER: MALE / FEMALE BIRTHDAY: _________ /_________ /_________ AGE: ________ SOCIAL SECURITY NUMBER: ________________________________________________________________________ MARITAL STATUS: SINGLE MARRIED DIVORCED SEPERATED WIDOWED SPOUSES NAME: ________________________________________________________________________ EMERGENCY CONTACT: NAME: _____________________________ PHONE: _____________________________ WHO REFERRED YOU?: _______________________________________________________________________ CONTACT INOFRMATION ADDRESS: ________________________________________________________________________ CITY: _______________________________________ STATE: ______ ZIP CODE: ___________ HOME PHONE: ________________________________________________________________________ CELL PHONE: ________________________________________________________________________ HOME EMAIL ADDRESS: ________________________________________________________________________ WORK: PHONE:_____________________________ EMAIL: ______________________________ CONDITION INFORMATION REASON FOR VISIT: ___________________________________________ MARK AREAS OF SYMPTOMS: DATE SYMPTONS STARTED?: ___________________________________________ GETTING WORSE OR BETTER?: ___________________________________________ RATE PAIN 0-10: ___________________________________________ TYPE OF PAIN: SHARP / DULL / BURNING / CRAMPING / THROBBING MY PAIN INTERFERES WITH: WORK / SLEEP / DAILY ROUTINE / RECREATION FREQUENCY OF MY PAIN: CONSTANT / COMES AND GOES CHIROPRACTIC GOALS?: ________________________________________________________________________ ACCIDENT?: YES / NO AUTO / HOME / WORK / OTHER ________________________________
- 2. HEALTH HISTORY FORM SHEA FAMILY CHIROPRACTIC 858-312-5066 10720 THORNMINT ROAD SUITE B, SAN DIEGO CA 92127 PATIENT NAME:________________________________________________________________DATE:______________ HEALTH HISTORY CARE CURRENTLY RECEIVING: CHIROPRACTIC / MASSAGE / MEDICATION / SURGERY / OTHER: ____________________ LAST DATE OF: SPINAL EXAM: _______ XRAY: _______ MRI: _______ BONE SCAN: _________ PLEASE CIRCLE ANY CONDITIONS THAT YOU CURRENTLY SUFFER FROM, AND CHECK ANY THAT YOU PREVIOUSLY HAD: AIDS/HIV ALCOHOLISM ALLERGY SHOTS ANEMIA ANOREXIA APPENDICITIS ARTHRITIS ASTHMA BLEEDING BREAST LUMP BRONCHITIS BULIMIA CANCER CATARACTS CHEMICAL DEPENDENT CHICKEN POX DIABETES EMPHYSEMA EPILEPSY FRACTURES GLAUCOMA GOITER GONORRHEA GOUT HEART DISEASE HEPATITIS HERNIA HERNIATED DISCO HERPES HIGH CHOLESTEROL KIDNEY DISEASE LIVER DISEASE MEASLES HEADACHES MISCARRIAGE MONO MS MUMPS OSTEOPOROSIS PACEMAKER PARKINSONS PINCHED NERVE PNEUMONIA POLIO PROSTATE PROBLEM PROTHESIS PSYCHIATRIC CARE RHEUMATOID ARTH RHEUMATIC FEVER SCARLET FEVER STROKE SUICUDE ATTEMPT THYROID PROBLEM TONSILLITIS TB TUMORS, GROWTHS TYPHOID FEVER ULCERS VAGINAL INFECTIONS VENEREAL DISEASE WHOOPING COUGH COLDS FLU VIRAL INFECTIONS VISION PROBLEMS FIBROMYALGIA MIGRAINES OTHER ACTIVITY EXERCISE WORK ACTIVITY HABITS NONE ___ SITTING ___ HOURS A DAY? ____________ SMOKING ___ HOW OFTEN? ____________ MODERATE ___ STANDING ___ HOURS A DAY? ____________ ALCOHOL ___ HOW OFTEN? ____________ DAILY ___ LIGHT LABOR ___ HOURS A DAY? ____________ CAFFINE ___ HOW OFTEN? ____________ EXTREME SPORT ___ HEAVY LABOR ___ HOURS A DAY? ____________ STRESS ___ HOW OFTEN? ____________ INJURIES / SURGERIES FALLS: _________________________________________________ DATE: _________________ HEAD INJURIES / WHIPLASH: _________________________________________________ DATE: _________________ FRACTURES / DISLOCATIONS: _________________________________________________ DATE: _________________ SURGERIES: _________________________________________________ DATE: _________________ CANCER: _________________________________________________ DATE: _________________ MEDICATIONS / VITAMINS / HERBS / MINERALS PLEASE LIST ALL MEDICATIONS, VITAMINS, HERBS AND MINERALS THAT YOU ARE CURRENTLY TAKING: __________________________________________________________________________________________________ __________________________________________________________________________________________________ I HEREBY AUTHORIZE THE DOCTOR; AND/OR HIS ASSOCIATES TO EXAMINE ME, AND TO PERFORM ANY NECESSARY DIAGNOSTIC PROCEDURES, INCLUDING X-RAY TO FULLY EVALUATE MY CONDITION FOR THE PRESENCE OF VERTEBRAL SUBLUXATION. PATIENT SIGNATURE: ___________________________________________________________ DATE: _______________