New Client Information Form About You Today s Date: / / Name: What do you prefer to be called? Male Female Birth Date: / / Age: Occupation: Home Address: City: State: ZIP: Email Address: Home Phone: Other Phone: Referred by: Occupation: Work Phone: Marital Status: Single Married Divorced Separated Widowed Spouse s Name: Reason for visit Have you ever seen a chiropractor before? Y/N If so, please explain: The reason for this visit is a result of: Work Sports Auto Trauma Other Chronic Explain what happened: Please describe the pain and it s location: When did this condition begin? Is this condition getting worse? Yes No Constant Comes & goes Is this condition interfering with your: Work Sleep Daily Routine If so, please explain: Have you had this or similar conditions in the past? Y/N If so, please explain: Have you been treated by a Medical Physician for this condition? Y/N If so, please explain:
Excelsior Health Center New Client Information Form 2 Description of Physical Problems Please check the box closest to the area(s) of injury or discomfort and fill in the intensity level for that area. Pain Scale Extreme Pain 10 1 Discomfort Right Left Left Right Right Front Back Left Additional Information You Wish to Provide
Excelsior Health Center New Client Information Form 3 Indicate the frequency of your symptoms using the following numbers: 1 = Rarely 2 = From time to time 3 = Often Patient Name Date / / Section A Lower bowel gas several hours after eating Burning stomach sensation, eating relieves Coated tongue Indigestion 1/2-1 hr after eating (up to 3-4 hours after) 3+ carbonated drinks per week Difficult bowel movements Ulcers? / Colitis? / Gastritis? Stomach bloating after eating Excessive belching/burping Bad breath Alternating diarrhea/constipation Have pets (dogs, cats, farm animals, etc) Rectal itching Can t gain weight International travel Stomach/intestinal cramping/diarrhea Section B Afternoon headaches Get shaky if hungry Faintness if meals delayed Heart palpitates if meals missed or delayed Eat when nervous Awaken after few hours of sleep Hard to get back to sleep Crave candy of coffee in afternoon Abnormal craving for sweets or snacks Thirsty much of the time History of diabetes Blurred vision/failing eyesight Breath smells sweet Tingling, numbness, prickling sensation in extremities Section C Bruise easily, black & blue spots Sigh frequently Aware of breathing heavily Open window in closed room Suceptible to colds & fevers Swollen ankles, worse at night Muscle cramps, worse during night Shortness of breath on exertion Nosebleeds Ringing in the ears Heart palpitations Dull pain in chest/radiating into left arm (worse on exertion) Hands & feet go to sleep easily Numbness in extremities Tendency to anemia Tension under breastbone or feeling tightness (worse on exertion) Blushing with no apparent cause Black stool (no iron supplementation) Poor concentration Slurred speech Headaches Weakness/fatigue Out of breath frequently e.g. going up stairs Nervousness
Excelsior Health Center New Client Information Form 4 Section D Pain under right side of rib cage Skin rashes frequent Bitter metallic taste in mouth in morning Bowel movements painful or difficult Low energy, weakness, exhaustion Greasy/fatty foods upset stomach Bruises easily Frequent headaches Stool is light colored Pain between shoulder blades Laxatives used often History of gallbladder attacks or gallstones History of heaptitis History of jaundice Sneezing attacks Itchy skin, worse at night Dry, flaky skin, hair General feeling of poor health Aching muscles Swollen feet and/or legs Section E Impaired hearing Decrease in appetite Ringing in ears Constipation Puffy hands/face Tired/sluggish Miscarriages Infertility Mental sluggishness/forgetfulness Headache upon rising; wears off during day Slow pulse, below 65 Cold hands and feet Gains weight easily Weight gain around hips Outer third of eyebrow thinning Emotional Flush easily Night sweats Hair loss Section F Hip and joint pain Receding gums and/or dental cavities Tendency towards slouching/weak Bone loss/osteoperosis in family Crunching, creaking joints Section G Exposure to fumes (paint, salon, car) Use pesticides on garden Live near power lines / high tension wires Have mercury amalgams (silver) in mouth Skin disorders (psoriasis, eczema, etc.) Loss of hair Hormone disorders History of cancer/personal or familial
Excelsior Health Center New Client Information Form 5 Section H Muscle aches, stiffness, cramping and pains Chiropractic adjustments don t hold Whiplash and/or ligament trauma/strain Fatigue, sluggishness Upper or lower back pain Stiff neck and shoulders Section I Low blood pressure Chronic fatigue Low energy, lack of stamina General malaise, unhappiness Tendency to hives Arthritic tendency Excessive perspiration Colds/flu often Weakness after illness Dark circles under the eyes Crave salty foods Feeling unrefreshed upon waking Allergies Exhaustion - muscular & nervous Respiratory disorders Swollen ankles Dizzy when stand up too fast Decreasing appetite Irritable Bright lights irritate Section J Female only Painful menses Premenstrual tension Very easily fatigued Depressed feeling Menstruation excessive and prolonged Painful breasts (monthly) Lumpy breasts, worse at menses Have taken birth control pills Menopause, hot flashes, etc. Menses scantly or irregular Acne, worse at menses Vaginal discharge/yeast etc. Male only Tired too easily Urination difficult Night urination frequent Pain on inside of legs or heel Feeling of incomplete bowel evacuation Prostate trouble Leg nervousness at night Diminished sex drive
Excelsior Health Center New Client Information Form 6 Section M Chronic urination Rose colored (bloody) urine Dripping after urination Difficulty passing urine Cloudy urine Rarely need to urinate Frequent bladder infections Painful/burning when urinating Urination when cough or sneeze Strong smelling urine Mild back pain Interrupted urine stream Tingling in joints Joint and muscle pain/cramping Can t hold urine Dark circles under eyes Frequent urge to urinate but passes only small amounts Section N Medications you are currently taking: How often do you take (or have taken) antibiotics? Reaction to vaccinations? Y/N How many silver amalgams do you have in your mouth? Root canals? Crowns/bridges? Were your wisdom teeth impacted Y/N Other Dental problems Y/N Allergies Y/N Are you experiencing bone loss or osteoporosis? Y/N Do you smoke? Y/N Diagnosed for parasites? Y/N Diagnosed or history of Candida? Y/N Drink 6-8 glasses of water daily? Y/N Hormone replacement medications? Y/N Important: Please list below you main health complaints in order of importance 1. 2. 3. 4.
Excelsior Health Center New Client Information Form 7 You are invited to discuss any questions regarding services. The best health services are based on a friendly, mutual understanding between provider and client. Our policy requires payment in full for all services rendered at the time visit, unless other arrangements have been made. If you are going to be more than 10 minutes late for an appointment, it will be necessary to reschedule. You agree to pay a $35 charge for a first missed visit. After second or more missed appointments, you agree to pay the full appointment charge of $60. I authorize Dr. Reeves to perform any necessary services needed during diagnosis and treatment. I also authorize the provider to release any information required to process insurance claims. I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes in my health status. Signature: Date: / / Done filling out the form? Take these next steps before coming in for your appointment: Save the PDF file to your computer. Attach the file to an email and send it to: cschiro61@comcast.net We will evaluate your form and be ready for you when you come in for your appointment. 1255 Lake Plaza Dr. Suite 140 Colorado Springs, CO 80906 719.527.0062 excelsiorhealthcenter.com