New Patient Health History Form Patient Data First Name Last Name Date Email Address Mailing Address Address City State Zip Code Phone Number Referred By Age Date of Birth Social Security Number Number of Children Occupation Employer Marital Status Spouse's Name Spouse's Occupation Spouses's Employer Spouse's Health Status Emergency Contact Phone Number Current Complaints Nature of Injury Automobile* Work Other Please Describe Date of Injury Date symptoms appeared Have you ever had same conditions? Yes No If yes, when? List of other practitioners seen for this injury/condition Have you ever been under chiropractic care? No Yes If yes, please describe Insurance Information Name of responsible for payment Phone Number Do you have health insurance? No Yes Name of company Insurance Company Name *If an auto accident, please provide Contact Person *If an auto accident, please provide Phone Number *If an auto accident, please provide Claim Number *If an auto accident, please provide If you are human, leave this field blank.
