Last Name First Name Address City State Zip Primary Phone

Last Name First Name Address City State Zip Primary Phone
NEW YORK CHIROPRACTIC COLLEGE NEW PATIENT REGISTRATION
Seneca Falls Health Center – Rochester Health Center- Levittown Health Center- Depew Health Center- Campus Health Center
Welcome to our Health Center! Your Health History is important to us.
Please fill out this form COMPLETELY.
Today’s Date:
Patient Title: ☐Mr. ☐ Mrs. ☐ Ms. ☐ Miss ☐ Dr. ☐ Prof. ☐ Rev.
Last Name
First Name
Address
City
Primary Phone (
)
Email:
Date of Birth:
/
/
Age
Marital Status: (Check One) ☐ Single
Emergency Contact:
Primary Care Provider:
Primary Care Provider Address:
State
Mobile Phone (
Zip
)
Sex: ☐ Male ☐Female ☐Other
☐ Married ☐ Other
Phone: (
)
Phone: (
)
☐ Please do not share the results of this visit with this provider
Race: Please Check One
☐ White
☐ Black/African American
☐ American Indian/Alaskan Native
☐ Asian
☐ Native Hawaiian/other Pacific Island
☐ Other
☐ Choose not to Specify
Ethnicity: Please Check One
☐ Hispanic or Latino
☐ Not Hispanic or Latino
☐ Choose not to Specify
Preferred Language: Please Check One
☐ English
☐ Spanish ☐ Chinese ☐ French
☐ Tagalog
☐ American Sign Language
☐ Other
☐ Choose not to Specify
Are you the patient, or are you completing this for the patient?
☐ I am the patient. ☐ I am completing this for the patient. Is the patient a minor? ☐ Yes ☐ No
If you are completing this form for the patient, please enter your name:
Employment Status: Please Check One
☐ Employed Full Time
☐ Employed Part-time ☐ FT Student
☐ Retired
☐ Self-Employed
☐ Other
Employer
Address
Name
City
State
Employer Phone: (
)
Position:
Please Continue on the Reverse
1|Page
☐ PT Student
ZIP
Patient Name:
Insurance Information
Subscriber’s Name
Subscriber’s Address
Relationship to Patient (If not Patient)
Insurance Company
Policy Number
Is Patient covered by additional insurance? ☐ Yes ☐ No
If Yes, Subscriber’s Name:
Subscriber’s Address
Relationship to Patient (If not Patient)
Insurance Company
Policy Number
Date of Birth
Date of Birth
Please tell us how you heard about us:
☐ Physician Referral (Please indicate Name)
☐ Personal Referral (Please indicate Name)
☐Phone Book ☐ Internet Search ☐ Other (Please Specify)
Check
Please review the following statements and sign on the last line indicating your agreement
Here
Privacy Verification: I know I may request a copy of the Privacy Policy and understand it describes
how my personal health information (PHI) is protected and released on my behalf for seeking
☐
reimbursement from any involved third parties.
Permission to Contact: I grant permission to be called to confirm or reschedule my appointment
and to be sent occasional cards, letters, emails or health information as an extension of my care in
☐
this office.
Payment Verification: I acknowledge that any insurance I may have is an agreement between the
carrier and me and that I am responsible for the payment of any covered or non-covered services
☐
I receive
General Verification: To the best of my ability, the information I have supplied today is complete
☐
and truthful. I have not misrepresented the presence, severity or cause of my health concerns.
Patient Signature:
Date:
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2|Page
New Patient Information
Date:
Patient Name:
CURRENT MEDICATIONS: Please list all prescriptions, over-the-counter medicines and supplements)
including frequency and dosage (if known). If there are NO current medications, check here ☐
1.
3.
5.
7.
2.
4.
6.
8.
Please list any ALLERGIES you have to medications. If NO known allergies, check here ☐
1.
3.
2.
4.
Do you use tobacco of any type? ☐ Yes ☐ No ☐ Former Tobacco User ☐ Never Used Tobacco
If Yes, how often do you use tobacco? ☐ Current every day user ☐ Current sometimes user
If you are a tobacco user, what is your interest in quitting on a scale where
0 is “No Interest” and 10 is Very Interested?
☐0
☐1
☐2
☐3
☐4
☐5
☐6
☐7
☐8
☐9
Do you presently have a diagnosis of Hypertension?
☐ Yes ☐ No
Do you presently have a diagnosis of Diabetes? ☐
☐ Yes ☐ No
If “Yes” to Diabetes, what kind?
☐ Type I ☐ Type II
If “Yes” to Diabetes, do you know your A1C level?
☐ Yes ☐ No ☐ Not Sure
Comments regarding your Diabetes diagnosis:
☐ 10
YOUR SYMPTOMS TODAY
Please describe your symptoms:
When did your symptoms start? Month
How did your symptoms begin?
Day
Year
Please indicate the location and severity of your symptoms on the Pain Diagram given to you today
How often do you experience your symptoms?
Do your symptoms affect other areas of your body?
To what extent does the pain radiate, shoot or travel?
What makes your pain better or worse?
(Things such as certain movements, certain activities, etc.)
Better:
Worse:
What time of day do you experience your symptoms? ☐ Morning ☐ Afternoon ☐ Evening ☐ Night
Prior Interventions: What have you done to relieve the symptoms? Please Check all that apply
☐ Prescription Medicine
☐ Acupuncture
☐ Over the Counter Medication
☐ Ice
☐ Homeopathic Remedies
☐ Chiropractic
☐ Physical Therapy
☐ Heat
☐ Massage
☐ Other
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3|Page
New Patient Information
Date:
Patient Name:
Is your condition due to an accident? ☐ Yes ☐ No
To who have you reported this accident?
☐ Auto Insurance ☐ Employer ☐ Workers’ Comp. ☐ Other ☐ Not Reported
Is there anything else we should know about your condition?
Please check the boxes if you HAVE or HAD any of the listed conditions
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Musculoskeletal
No Issues
Osteoporosis
Arthritis
Scoliosis
Neck Pain
Back Problems
Hip Disorders
Knee Injuries
Elbow/Wrist Pain
TMJ Issues
Foot/ankle Pain
Poor Posture
Shoulder Problems
Other
Neurological
No Issues
Anxiety
Depression
Headache
Dizziness
Pins and Needles
Numbness
Other
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Cardiovascular
No Issues
High Blood Pressure
Low Blood Pressure
High Cholesterol
Poor Circulation
Angina
Excessive Bruising
Other
Digestive
No Issues
Anorexia/Bulimia
Ulcer
Food sensitivities
Heartburn
Constipation
Diarrhea
Other
Sensory
No Issues
Blurred Vision
Ringing in Ears
Hearing Loss
Loss of Smell
Loss of taste
Chronic Ear Infection
Other
Please explain any items you checked above:
ITEM
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Endocrine
No Issues
Thyroid Issues
Immune Disorders
Hypoglycemia
Frequent Infection
Swollen Glands
Low Energy
Other
Genitourinary
No Issues
Kidney Stones
Infertility
Bedwetting
Prostate Issues
Erectile Dysfunction
PMS Symptoms
Other
Constitutional
No Issues
Fainting
Low Libido
Poor Appetite
Fatigue
Erectile Dysfunction
Weakness
Other
EXPLANATION
Please Continue to the Next Page
4|Page
☐
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Respiratory
No Issues
Asthma
Apnea
Emphysema
Hay Fever
Shortness of Breath
Pneumonia
Other
☐
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Integumentary
No Issues
Skin Cancer
Psoriasis
Eczema
Acne
Swollen Glands
Rash
Other
New Patient Information
Date:
Patient Name:
Are there any past or current medical conditions you have not told us about?
Please list date(s) and reason(s) for any hospitalizations:
Date
Reason
Date
Reason
Please list any surgical procedures you have had:
Date
Procedure
Date
Procedure
Please list any other injuries not described above:
Date
Injury
Date
Injury
Family History
Relative
Health Condition or Illness
Mother
Father
Brother(s)
Sister(s)
Son(s)
Daughter(s)
Stress Information
On a scale of 0 to 10, where 0 means you have NO stress and 10 means a LOT OF STRESS, please indicate
your PHYSICAL stress level:
☐0
☐1
☐2
☐3
☐4
☐5
☐6
☐7
☐8
☐9
☐ 10
On a scale of 0 to 10, where 0 means you have NO stress and 10 means a lot of stress, please indicate
your EMOTIONAL stress level:
☐0
☐1
☐2
☐3
☐4
☐5
☐6
☐7
☐8
☐9
☐ 10
What are the major stressors in your life:
Please Continue on the Reverse
5|Page
New Patient Information
Date:
Patient Name:
Consumption, Sleeping , and Exercise Information
How much alcohol do you consume daily?
How many cups of coffee do you drink daily?
How much soda pop do you consume daily?
How much water do you drink daily?
Do you use recreational drugs?
☐ Yes ☐ No
Please rate your eating habits where 0 means your eating habits are UNHEALTHY and 10 means your
eating habits are HEALTHY:
☐0
☐1
☐2
☐3
☐4
☐5
☐6
☐7
☐8
☐9
☐ 10
What are your typical eating habits:
☐ Skip Breakfast
☐ 2 Meals per Day
☐ 3 Meals per Day
☐ Snacking Between Meals
On average, how many hours do you sleep at night?
What is your preferred sleeping position?
On a regular basis, how much do you exercise?
What would be the most significant thing you could do to improve your health?
What additional health goals do you have?
Patient Signature:
To be completed by Health Center Chiropractic Student:
Height:
inches Weight:
pounds
BP
6|Page
Pain Diagram
Patient’s Name:
Draw the location of your pain on body outlines and mark how bad it is on pain line at bottom of page.
Indicate location and the type of pain using the following chart:
1 – Ache
2 – Burning
3 – Numbness
4 – Pins and Needles
5 – Stabbing
6 – Other
No
Pain
Worst Pain
Possible
Please make a slash through this line as to the level of your pain
.
No
Pain
Worst Pain
Possible
Please make a slash through this line as to the level of your pain
Patient’s Signature
7|Page
Date:
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