Chiropractic New Patient Form - Sauvage Wellness Solutions

Date*

Name*

First Last

Phone*

Email

Address*

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

Emergency Contact*

First Last

Emergency Contact Phone*

What is bothering you today?*

Have you seen a doctor for this condition? Type of treatment and results?*

When did this condition began and has this occurred before?*

Do you suffer from any other condition other than which you are not consulting us for?*

Medical History

Have you had any major surgeries/operations*

Please add additional information for the above if needed.

Check any of the following diseases you have had.*

Check any of the following you have had the past 6 months*

Family History

Mother
Father
Brother
Sister
Spouse
Child

The following members have a same or similar problem as I do:

Females Only

When was your last period?

Females Only

Are you pregnant?

Please choose the type of care desired so that we may be guided by your wishes whenever possible.*

Most patients that see a chiropractor have one of two objectives in mind concerning their health care. Some patients come for symptomatic relief of pain or discomfort (Relief Care). Others are interested in having the cause of the problem as well as the symptoms corrected and relieved (Corrective Care).

Consent*

I agree to the privacy policy.

I understand and agree that health and accident policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that Sauvage Wellness Solutions will prepare any necessary reports and forms to assist me in making collection from the insurance company such as a Super Bill. However, I clearly understand and agree that all services rendered to me are charged directly to me and I am personally responsible for payment. I also understand that if I suspend or terminate, any fees for professional services rendered to me will be immediately due and payable.

I hereby authorize the Doctor to treat my condition as she deems appropriate. The patient also agrees that he/she is responsible for all bills incurred at this office.

Area of Complaint(s)

Please answer the questions below about your current area(s) of complaint to provide Dr. Sauvage with more information

Area of discomfort*

Please describe your area(s) of discomfort

Rate your CURRENT level of pain*

How much of your day do you have pain?*

Pain at it's WORST*

Pain at it's BEST*

My started….*

My pain has been getting:*

Approximate date the pain started.*

Activities that make my pain worse:*

For example: sitting, driving, lying down, lifting, squatting, chores…..

Activities that make my pain better:*

For example rest, ice, heat, stretching lying down, sitting, standing, medication….

Check those that describe your pain*

dull aching
sharp stabbing
throbbing
radiating
numbness
tingling
tightness
burning
discomfort

Check the time of the day the pain is worst*

morning
afternoon
evening
before bed
while sleeping
continuous throughout the day

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Comments

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