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New Patient Health History Form

New Patient Health History Form

Thank you for choosing Healy Chiropractic, LLC. Please fill out the following information and submit this form prior to your appointment date. If you do not know the answer, please leave the section blank.

Patient Data

First Name*

Last Name*

Date

Email (Your email will NOT be shared with any third parties, and is used for occasional office announcements and promotions.) *

Address

City

State

Zip

Telephone (Home)

Telephone (Work)

Referred By

Age

Birth Date

Number of Children

Occupation

Employer

Marital Status

Spouse's Name

Spouse's Occupation

Spouse's Employer

Spouse's Health Status

Emergency Contact

Phone

Nature of Injury

Automobile Work Other

Please Describe

Date of Injury

Date Symptoms Appeared

Have you ever had same condition?

No Yes

If yes, when

List other practioners seen for this injury/condition

Have you ever been under chiropractic care?

No Yes

If yes, please describe

Name of party responsible for payment

Phone

Do you have health insurance?

No Yes

Name of company

Insurance company name

Contact person

Phone

Claim #

Have you been treated for any conditions in the last year?

No Yes

If yes, please describe

Date of last physical exam

Is there a chance that you are pregnant?

No Yes

Have you had X-rays taken?

No Yes

If Yes, where?

What medications are you taking and for what conditions (Please list dosage and amounts, etc).

What vitamins, minerals, or herbs do you currently take? (Please list for what condition, dosage, and frequency).

Broken bones?

No Yes

Briefly explain

Been hospitalized?

No Yes

Briefly explain

Been in auto accident?

No Yes

Briefly explain

Had Sprains/Strains?

No Yes

Briefly explain

Been struck unconscious?

No Yes

Briefly explain

Had surgery?

No Yes

Briefly explain

Family members - Present and past health conditions (Example: heart disease, cancer, diabetes, arthritis, etc.)

Do you experience pain every day?

No Yes

Do your symptoms interfere with daily life?

No Yes

Does pain wake you up at night?

No Yes

Are your symptoms worse during certain times of the day?

No Yes

Do changes in weather affect your symptoms?

No Yes

Do you wear orthotics?

No Yes

Do you take vitamin supplements?

No Yes

What activities aggravate your symptoms?

Alcohol

No Yes

Coffee

None Light Moderate Heavy

Tobacco

None Light Moderate Heavy

Drugs

None Light Moderate Heavy

Exercise

None Light Moderate Heavy

Sleep

None Light Moderate Heavy

Appetite

None Light Moderate Heavy

Soft Drinks

None Light Moderate Heavy

Water

None Light Moderate Heavy

Salty Foods

None Light Moderate Heavy

Sugary Foods

None Light Moderate Heavy

Artificial Sweeteners

None Light Moderate Heavy

Have you ever suffered from:

Alcoholism Allergies Anemia Arteriosclerosis Arthritis Asthma Back Pain Breast Lump Bronchitis Bruise Easily Cancer Chest Pain Cold Extremities Constipation Cramps Depression Diabetes Digestion Problems Dizziness Ears Ring Excessive Menstruation Eye Pain or Difficulties Fatigue Frequent Urination Headache Hemorrhoids High Blood Pressure Hot Flashes Irregular Heart Beat Irregular Cycle Kidney Infection Kidney Stones Loss of memory Loss of balance Loss of smell Loss of taste Lumps In Breast Neck Pain or Stiffness Nervousness Nosebleeds Pacemaker Polio Poor Posture Prostate Trouble Sciatica Sexually Transmitted Infection Shortness of breath Sinus Infection Sleep problems or Insomnia Spinal Curvatures Stroke Swelling of ankles Swollen Joints Thyroid Condition Tuberculosis Ulcers Varicose Veins Other

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

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Location

1017 School St.,
Veazie, ME 04401

(207) 989-4401

Monday

8:00 am - 5:00 pm

Tuesday

8:00 am - 5:00 pm

Wednesday

8:00 am - 5:00 pm

Thursday

8:00 am - 5:00 pm

Friday

8:00 am - 5:00 pm

Saturday

Closed

Sunday

Closed

Request an Appointment

We will reach out to confirm a time ASAP

First Name*

Last Name*

Services Needed

Chiropractic Care Gait Analysis Nutrition Sports Rehabilitation

Patient Type *

Phone Number *

Email *

Preferred Date*

How did you hear about us? *

Comments

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

Error!

(207) 989-4401

WHERE IS YOUR PAIN?

Learn how we can help with your pain

Head and Neck

Upper Back

Shoulder or Clavicle

MID-BACK

LOWER BACK

Elbow, Hand, and Wrist

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