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About Us
- Meet the Doctor
- Testimonials
Services
Patient Center
Blog
Contact Us
- Book Appointment

Book Appointment (480) 968-7767

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New Patient Health History Form

New Patient Health History Form

In order to provide you the best possible care, please complete this form and bring it to your first appointment. All information is strictly CONFIDENTIAL.

Patient Data

First Name

Last Name

Date

* Your email will NOT be shared with any 3rd parties, and is used for occasional office announcements and promotions.

Mailing address

Address, City, State, Zip

Telephone (Work)

Telephone (home)

Referred By

Age

Birth Date

Social Security #

Number of Children

Occupation

Employer

Marital Status

Spouse's Name

Spouse's Occupation

Spouse's Employer

Spouse's Health Status

Emergency Contact

Phone

Current Complaints

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 of other practitioners seen for this injury/condition

Have you ever been under chiropractic care?

Yes No

If yes, please describe

Insurance Information

Name of party responsible for payment

Phone

Do you have health insurance?

Yes No

Name of company

* If an auto accident, please provide:

Insurance Company Name

Contact Person

Phone

Claim #

Signatures

Name of the insured

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

For patient’s signature please enter your complete name thanks

Date

For spouse’s or guardian’s signature please enter your complete name thanks

Date

Medical History

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

Yes No

If yes, please describe

Date of last physical exam

Is there a chance that you are pregnant?

Yes No

Have you had X-rays taken?

Yes No

If Yes, where?

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

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

Have you ever

Broken bones?

Yes No

Briefly Explain

Been hospitalized?

Yes No

Briefly Explain

Been in an auto accident?

Yes No

Briefly Explain

Had Sprains/Strains?

Yes No

Briefly Explain

Been struck unconscious?

Yes No

Briefly Explain

Had surgery?

Yes No

Briefly Explain

Family History

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

Do you experience pain every day?

Yes No

Do your symptoms interfere with daily life?

Yes No

Does pain wake you up at night?

Yes No

Are your symptoms worse during certain times of the day?

Yes No

Do changes in weather affect your symptoms?

Yes No

Do you wear orthotics?

Yes No

Do you take vitamin supplements?

Yes No

What activities aggravate your symptoms?

Habits

Alcohol

None Light Moderate Heavy

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/Conditions 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 Shortness of breath Sinus Infection Sleep problems or Insomnia Spinal Curvatures Stroke Swelling of ankles Swollen Joints Thyroid Condition Tuberculosis Ulcers Varicose Veins Venereal Disease Other

Have you ever suffered from (Other)

Consultation History Form

Patient's Name

Date

Chief complaint

How long

How often

When at its worst it feels like

What have you done to try and handle

Medications

List any accidents or injuries have you had in your life (i.e., Slips, falls, motor vehicle, motorcycle, bicycle, sports, or work related, etc.)

How has your

pain affected your life

How has it affected your work

How has it affected your home life

How has it affected your hobbies

What are some things you used to do before you had pain that you would like to do again if this was not a problem

Can you remember a time, a specific time, before your pain started and affected you in the ways listed above?

Yes No

Tell me about it, what was it like, how did you feel, what did you do, etc.

Compare for me how your life was then compared to now

If you were to not handle this now and it gets worse how would that affect your life:

Since this problem first began has it gotten worse?

Yes No

If yes, does it hurt more (scale of 1-10), hurt more frequent, and when it hurts does the pain last longer:

If there were a way to fix this problem so that you would not have to suffer with it any longer would you want to?

Yes No

What may prevent you from getting this problem fixed:

Custom Field

Treatment Options Checklist

Explanation of degenerative conditions: Done:______

Prescription/over the counter pain relievers: Done:______

Cortisone: Done:______

Physical therapy: Done:______

Surgery: Done:______

Visco-supplementation: Done:______

Regenerative medicine: Done:______

Explain the difference between Regenerative Care and Relief Care: Done:______

Show the regenerative medicine video: Done:______

Schedule them with the medical professional, if qualified: Done:______

Notes:

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

Thank you. Your submission has been sent.

Error!

Monday

Closed

Tuesday

11:00 am - 1:00 pm

4:00 pm - 6:00 pm

Wednesday

Regenerative Medicine by Appointment Only

Thursday

11:00 am - 1:00 pm

4:00 pm - 6:00 pm

Friday

Regenerative Medicine by Appointment Only

Saturday

Closed

Sunday

Closed

Monday

Closed

Tuesday

11:00 am - 1:00 pm 4:00 pm - 6:00 pm

Wednesday

Regenerative Medicine by Appointment Only

Thursday

11:00 am - 1:00 pm 4:00 pm - 6:00 pm

Friday

Regenerative Medicine by Appointment Only

Saturday

Closed

Sunday

Closed

Location

Find Us On The Map!

--mi

Community Holistic Health Clinic LTD

2504 S Rural Rd
Tempe, AZ 85282

(480) 968-7767

[email protected]

Regenerative Medicine by appointment only

Massage therapy Provided by appointment only. Please call (480) 968-7767 to schedule.

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