New Patient Form - Pregnancy - Lander Chiropractic

Step 1 of 11

Patient Data

Name(Required)

First Last

Date(Required)

Month

Day

Year

Email(Required)

Mailing Address

Address(Required)

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

Cell Phone

Home Phone

Referred By

Age(Required)

Date of Birth(Required)

Month

Day

Year

Social Security Number(Required)

Number of Children(Required)

Occupation(Required)

Employer

Marital Status(Required)

Spouse's Name(Required)

Spouse's Occupation(Required)

Spouse's Employer(Required)

Spouse's Health Status(Required)

Emergency Contact(Required)

Emergency Contact Phone(Required)

How would you like to receive appointment reminders?(Required)

text

Questions Regarding Your Pregnancy

Is this your first pregnancy?(Required)

Yes

If this is not your first pregnancy, please list number of pregnancies(Required)

If this is not your first pregnancy, please list number of children(Required)

Date of Last Menstrual Cycle(Required)

Due Date?(Required)

Are you under the care of an

OB/GYN

Midwife

Name?(Required)

Please describe any current complaints (if none, please enter N/A):(Required)

Have you ever been under chiropractic care?(Required)

Yes

Have you been under chiropractic care during pregnancy?(Required)

Yes

Are you taking prenatal vitamins?(Required)

Yes

Are you taking any medications?(Required)

Yes

Please list any medications:(Required)

What is your birth plan?(Required)

Insurance Information

Name of party responsible for payment

Phone Number

Do you have health insurance?(Required)

Yes

Name of Company(Required)

Insurance Company Name(Required)

Contact Name(Required)

Phone Number(Required)

Claim #

Billing Address

Name of the Insured

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Patient's Signature(Required)

Date

Month

Day

Year

Spouse's or Guardian's Signature

Date

Month

Day

Year

Medical History

Have you been treated for any condition in the last year?(Required)

yes

Please describe(Required)

Date of last physical exam(Required)

Month

Day

Year

Have you had X-rays taken?(Required)

yes

Where were the X-rays taken?(Required)

Have you ever:

Broken bones?(Required)

yes

Breifly explain hospitalizations(Required)

Been hospitalized?(Required)

yes

Breifly explain any broken bones(Required)

Been in an auto accident?(Required)

yes

Breifly explain any auto accidents(Required)

Had sprains/strains?(Required)

yes

Breifly explain any sprains/strains(Required)

Been struck unconscious?(Required)

yes

Breifly explain being struck unconscious(Required)

Had surgery?(Required)

yes

Breifly explain any surgeries(Required)

Family History

Please list any family members and any past or current health conditions (Example: heart disease, cancer, diabetes, arthritis, etc.) If none, please enter none.(Required)

Your Current Condition

Do you experience pain every day?(Required)

yes

Do your symptoms interfere with daily life?(Required)

yes

Does pain wake you up at night?(Required)

yes

Are your symptoms worse during certain times of the day?(Required)

yes

Do changes in weather affect your symptoms?(Required)

yes

Do you wear orthotics?(Required)

yes

Please list any activities that aggravate your symptoms:

Current Habits

Alcohol(Required)

none

light

moderate

heavy

Coffee(Required)

none

light

moderate

heavy

Tobacco(Required)

none

light

moderate

heavy

Drugs(Required)

none

light

moderate

heavy

Exercise(Required)

none

light

moderate

heavy

Sleep(Required)

none

light

moderate

heavy

Appetite(Required)

none

light

moderate

heavy

Soft Drinks(Required)

none

light

moderate

heavy

Water(Required)

none

light

moderate

heavy

Salty Foods(Required)

none

light

moderate

heavy

Sugary Foods(Required)

none

light

moderate

heavy

Artificial Sweeteners(Required)

none

light

moderate

heavy

Please check if you currently have or have a history of:

Alcoholism

Currently Have

Have a History of

Allergies

Currently Have

Have a History of

Anemia

Currently Have

Have a History of

Arteriosclerosis

Currently Have

Have a History of

Arthritis

Currently Have

Have a History of

Asthma

Currently Have

Have a History of

Back Pain

Currently Have

Have a History of

Breast lump

Currently Have

Have a History of

Bronchitis

Currently Have

Have a History of

Bruise Easily

Currently Have

Have a History of

Cancer

Currently Have

Have a History of

What type of cancer?(Required)

Chest Pain/Conditions

Currently Have

Have a History of

Cold extremities

Currently Have

Have a History of

Constipation

Currently Have

Have a History of

Cramps

Currently Have

Have a History of

Depression

Currently Have

Have a History of

Diabetes

Currently Have

Have a History of

Digestion Problems

Currently Have

Have a History of

Dizziness

Currently Have

Have a History of

Ears Ring

Currently Have

Have a History of

Excessive Menstruation

Currently Have

Have a History of

Eye Pain/Difficulties

Currently Have

Have a History of

Fatigue

Currently Have

Have a History of

Frequent Urination

Currently Have

Have a History of

Headache

Currently Have

Have a History of

Hemorrhoids

Currently Have

Have a History of

High Blood Pressure

Currently Have

Have a History of

Hot Flashes

Currently Have

Have a History of

Irregular Heart Beat

Currently Have

Have a History of

Irregular Cycle

Currently Have

Have a History of

Kidney Infection

Currently Have

Have a History of

Kidney Stones

Currently Have

Have a History of

Loss of Balance

Currently Have

Have a History of

Loss of Memory

Currently Have

Have a History of

Loss of Smell

Currently Have

Have a History of

Loss of Taste

Currently Have

Have a History of

Morning Sickness

Currently Have

Have a History of

Neck Pain or Stiffness

Currently Have

Have a History of

Nervousness

Currently Have

Have a History of

Nosebleeds

Currently Have

Have a History of

Pacemaker

Currently Have

Have a History of

Polio

Currently Have

Have a History of

Poor Posture

Currently Have

Have a History of

Sciatica

Currently Have

Have a History of

Shortness of breath

Currently Have

Have a History of

Sinus Infection

Currently Have

Have a History of

Sleep problems/insomnia

Currently Have

Have a History of

Spinal Curvatures

Currently Have

Have a History of

Stroke

Currently Have

Have a History of

Swelling of ankles

Currently Have

Have a History of

Swollen Joints

Currently Have

Have a History of

Thyroid Condition

Currently Have

Have a History of

Ulcers

Currently Have

Have a History of

Varicose Veins

Currently Have

Have a History of

Venereal Disease

Currently Have

Have a History of

Other:

Currently Have

Have a History of

Please list any others(Required)

Consent(Required)

Please check this box confirm that you have read and filled out all the information above. Please note: If you cannot make your appointment, please notify us within 24 BUSINESS hours. There is a $20.00 fee for any cancellation or rescheduled appointments less than 24 BUSINESS hours before your scheduled time or missed appointments.

Signature(Required)

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Call to Make an Appointment (714) 626-0074

New Patient Form – Pregnancy

Patient Data

Mailing Address

Questions Regarding Your Pregnancy

Insurance Information

Billing Address

Medical History

Have you ever:

Family History

Your Current Condition

Current Habits

Please check if you currently have or have a history of:

Lander Chiropractic