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Patient InTake Form
First Name
Last Name
Date of Birth
Cell
Email
Gender
Male
Female
Other
Age
Ethnicity
Hispanic
White alone, non-Hispanic
Black or African American alone, non-Hispanic
American Indian and Alaska Native alone, non-Hispanic
Asian alone, non-Hispanic
Native Hawaiian and Other Pacific Islander alone, non-Hispanic
Some Other Race alone, non-Hispanic
Multiracial, non-Hispanic
Others
Social Security#
Marital Status
Single
Married
Widowed
Divorced
Address (please include Apt number if any)
City
State
Zip Code
Insurance company
Aetna
Blue Cross Blue Shield
Cigna
United Healthcare
Empire Plan NYSHIP
UMR
Meritain Health
Others
ID#
Group#
Where / Who did you hear about us from? (from menu)
Google
Zocdoc
Friend / Family member refers
Other
Occupation and weekly hours you work
Emergency Contact’s Name:
Emergency Contact's Phone:
Have you had acupuncture before:
Yes
No
Have you had chiropractic before:
Yes
No
Have you had physical therapy before:
Yes
No
Are you currently pregnant?
Yes
No
No Sure
HIV positive?
Yes
No
Not Sure
Hepatitis Positive?
Yes
No
Not Sure
Chief Complain 1
Neck pain
Jaw pain/tightness (TMJ)
Shoulder pain
Arm pain
Elbow pain
Wrist pain
Hand (joint) pain
Upper back pain
Middle back pain
Lower back pain
Tailbone pain
Hip pain
Knee pain
Leg pain
Ankle pain
Foot pain
Heel pain
Swelling / Edema
Insomnia
Tiredness / Fatigue
Anxiety / Depression
Headache / Migraine
Dizziness
Bell's Palsy
Acne
Constipation
Nausea and Vomiting
Digestive disorders
Weight management
Irregular menstrual cycle
Menstrual pain
Infertility
Women’s health
Menstrual treatment
Hormonal inbalance
Chief Complain 2
Neck pain
Jaw pain/tightness (TMJ)
Shoulder pain
Arm pain
Elbow pain
Wrist pain
Hand (joint) pain
Upper back pain
Middle back pain
Lower back pain
Tailbone pain
Hip pain
Knee pain
Leg pain
Ankle pain
Foot pain
Heel pain
Swelling / Edema
Insomnia
Tiredness / Fatigue
Anxiety / Depression
Headache / Migraine
Dizziness
Bell's Palsy
Acne
Constipation
Nausea and Vomiting
Digestive disorders
Weight management
Irregular menstrual cycle
Menstrual pain
Infertility
Women’s health
Menstrual treatment
Hormonal inbalance
Chief Complain 3
Neck pain
Jaw pain/tightness (TMJ)
Shoulder pain
Arm pain
Elbow pain
Wrist pain
Hand (joint) pain
Upper back pain
Middle back pain
Lower back pain
Tailbone pain
Hip pain
Knee pain
Leg pain
Ankle pain
Foot pain
Heel pain
Swelling / Edema
Insomnia
Tiredness / Fatigue
Anxiety / Depression
Headache / Migraine
Dizziness
Bell's Palsy
Acne
Constipation
Nausea and Vomiting
Digestive disorders
Weight management
Irregular menstrual cycle
Menstrual pain
Infertility
Women’s health
Menstrual treatment
Hormonal inbalance
Complaints are not listed above(if any)
Past Medical History
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