FEMALE NEW PATIENT INTAKE FORM - We Care Chiropractic

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FEMALE NEW PATIENT INTAKE FORM

APPLICATION FOR CARE AT WE CARE CHIROPRACTIC

First Name *

Last Name *

Phone *

Address

City

State

Zip

Email *

Treatments of Interest *

Chiropractic Care

Regenerative Joint Repair Therapies

Hormone Optimization (Biote) or Medical Weight Loss

Preferred Clinic Location: *

Bozeman

Billings

Helena

Missoula

Today's Date

Birth Date

Occupation

How did you hear about us?

Emergency/Alternative Contact Info

Emergency/Alternative Contact name:

Contact Phone Number

Relationship

Number of Children?

Do you currently have active cancer and/or are you currently treating cancer?

Yes

No

Tell us more about your cancer/treatment if applicable:

What health issues/problems are you most concerned about?

What have you done to treat the above problems?

Have your symptoms Improved, Stayed the Same or Gotten Worse with treatment?

Improved

Stayed the same

Gotten Worse

What makes your condition Worse?

What makes your condition Better?

What are the top priorities in you life right now?

What activities do you love doing?

Neurological/Endocrine/Metabolic (select all that apply)

Blood Pressure Issues ?

High

Low

List all Allergies:

List all Surgeries that you have had:

List any Prescription Drugs you are currently taking:

List any Supplements you are currently taking

Shoulder Pain ?

None

Left

Right

Both

Arm, Elbow, Wrist or Hand Pain ?

None

Left

Right

Both

Hip Problems ?

None

Left

Right

Both

Leg Problems ?

None

Left

Right

Both

Knee Problems ?

None

Left

Right

Both

Foot/Ankle Problems ?

None

Left

Right

Both

Numbness or Tingling

If Yes, where is the numbness or tingling? (If None, type NA)

Degeneration ?

If Yes, where is the degeneration? (if None, type NA)

Stiffness ?

If Yes, where are you stiff? (If None, type NA)

Do you Exercise?

Yes

No

How Long & Often do you Exercise?

How healthy do you eat? On a scale of 1-10 (10=awesome, 1=terrible)

Hormone Health

Height:

Current Weight

Goal Weight

Difficulty or Inability to Orgasm

Severe

Moderate

Mild

None

Acne

Severe

Moderate

Mild

None

Other symptoms or unique health circumstances to take into consideration

The first day of my last menstrual cycle was on ?

Pregnancy

I have been provided a full explanation of when I am most likely to become pregnant, and to the best of my knowledge, I am not pregnant.

By my signature below I am acknowledging that the doctor and or a member of the staff has discussed with me the hazardous effects of ionization to an unborn child, and I have conveyed my understanding of the risks associated with exposure to x-rays. After careful consideration I therefore, do hereby consent to have the diagnostic x-ray examination the doctor has deemed necessary in my case.

The information provided is accurate & true to the best of my knowledge

Signature

Clear

CONTACT INFO

804 North 19th Avenue

Bozeman, MT 59718

(406)-551-1677

Clinic hours

Mon, Wed, Thu:

7:45am – 10:00am

3:00pm – 6:00pm

Saturday:

By appointment

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