Dunn Chiropractic Clinic

WELCOME TO THE CLINIC NEW PATIENT INTAKE

New Patient Information Worksheet:

Thank you for taking your time to fill this out. It will reduce your wait at the clinic.

PAST HEALTH HISTORY:

FAMILY HEALTH HISTORY:

SOCIAL HISTORY:

PATIENT HEALTH HISTORY WORKSHEET:

Please label the Area(s) of Todays Pain on the picture below and list the Quality of Your Pain (Sharp, Dull, Radiating, Aching, Burning, Numbness)

A

ACTIVITIES OF DAILY LIVING (ADL) WORKHSEET

(Please check the number which most closely describes your "Activities Of Daily Living" today)

REVIEW OF SYSTEMS

I have read the above information and certify it to be true and correct to the best of my knowledge, and hereby authorize this office of Chiropractic to provide me with chiropractic care, in accordance with this state statutes. If my insurance will be billed, I authorize payment of medical benefits to George Siegfried, D. C. / Dunn Chiropractic Clinic / Westgate Wellness for the services performed. You can sign this form when you come to the clinic. Please go to Printable Forms under New Patient Center for HIPPA and Terms of Acceptance. Thank you!

Patient or Guardian Signature: _______________________________ Date: ___________________