Intake Form

Patient Information

First Name:*

Middle Name:

Last Name:*

Date of Birth:*

Gender:

Female
Male

Email:*

Enter Email Confirm Email

Best Contact Phone:

Phone Type:

Home Phone
Work Phone
Cell Phone

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Height:

Weight:

Marital Status:

Number of Children:

Occupation:

How Did You Hear About Our Office

Referred By:

Did you hear about us us through advertisement?

Yes
No

If "Yes" . . . Where?

Did you hear about us through phone or business directory?

Yes
No

If "Yes" . . . Where?

Personal Health History

What is the purpose of your visit?

Please list any health conditions that you have been treated for in the last year:

Have you had previous Chiropractic care?

Yes
No

Condition(s) Treated:

Date of last chiropractic visit:

Are you pregnant, have you had any signs of pregnancy? (female only)

Yes
No

List current medications:

(name, amount, frequency, length of use, reason for use)

List current vitamins, minerals, supplements, and herbs:

(name, amounts, frequency, length of use, reason for use)

Personal Incident History:

Had major sprains/strains/broken bones?

Yes
No

If Yes, did you receive professional care/treatment?

Yes
No

Briefly explain:

Been Hospitalized?

Yes
No

Briefly explain:

Had Surgery?

Yes
No

Briefly explain:

Been in Auto Accident?

Yes
No

If Yes, did you receive professional care/treatment?

Yes
No

Briefly explain:

Been Struck Unconscious?

Yes
No

Been Diagnosed with an Eating Disorder?

Yes
No

Briefly explain:

Had a Stroke?

Yes
No

Social History & Life Choices:

Alcohol

Daily
Weekly
Occasionally
Never

Caffeine Drinks & Products

Daily
Weekly
Occasionally
Never

Diet Food Products

Daily
Weekly
Occasionally
Never

Drugs

Daily
Weekly
Occasionally
Never

Energy Products or Over-the-Counter Stimulants

Daily
Weekly
Occasionally
Never

Exercise

Daily
Weekly
Occasionally
Never

Fresh & Homemade Foods

Daily
Weekly
Occasionally
Never

Processed, Packaged & Restaurant Foods

Daily
Weekly
Occasionally
Never

Soft Drinks

Daily
Weekly
Occasionally
Never

Tobacco

Daily
Weekly
Occasionally
Never

Water

Daily
Weekly
Occasionally
Never

Health Problems & Concerns:

Please select all that you have had or currently have:

Check All That Apply

Other:

Do you have Diabetes? If so, what type?

Type I
Type II
Juvenile

Do you have any stomach/digestive issues?

Yes
No

Check All That Apply

Is there a behavior in your lifestyle that you feel is the most important to change?

Health Goals:

Goal #1

Goal #2

Goal #3

Terms & Agreement

*Fresh Start Wellness, LLC, products, programs, website, and services are not intended to replace medical treatment of any kind. We recommend consulting your doctor prior to making any changes to your diet, exercise, lifestyle, medications and/or supplementation. By accepting services you acknowledge, understand and agree that your are doing so on your own initiative and at your own risk and that in doing so, your health decisions are your responsibility and not the responsibility of Fresh Start Wellness, LLC. While the information conveyed in our programs and services and on our website were prepared to provide accurate information regarding topics related to general and specific health and wellness, the information is made available with the express understanding that Fresh Start Wellness, LLC is not dispensing medical advice and do not intend any of their information to be used for diagnosis or treatment. If you have any questions or concerns about your health and before starting or stopping any treatment or acting upon information related to any of our products and services, you should contact your own physician or health care provider.

Please select Agree to Submit:*

Agree

Pre-Appointment Intake Form

Patient Information

How Did You Hear About Our Office

Personal Health History

Personal Incident History:

Social History & Life Choices:

Health Problems & Concerns:

Health Goals:

Terms & Agreement