Phillips Family Chiropractic: New patient form to submit before your visit.


	New Patient Information
	If you would like to become a new patient, please fill out the form below to submit your information and someone will call you to schedule your first appointment. If you need more information, please see information on your visits to learn more.

	* Required Fields
*First Name:
*Last Name:
*Birth Date:		*Today's Date:
*Address:
Address:
*City:
*State:		*Zip Code :
*Home Phone:		Work Phone:
*Occupation:		Employer's Name:
Employer's Address:
Employer's Address:
City:
State:		Zip Code :
*Marital Status:		*Number of Children:
*Reason for Consulting our Office:
*How did you hear about us?

Your Health Profile
As a full spectrum Chiropractic office, we focus on your ability to be healthy. Our goals are, first, to address the issues that brought you to this office, and second, to offer you the opportunity of improved health potential and wellness services in the future. On a daily basis, we experience physical, chemical, and emotional stresses that can accummulate and result in serious loss of health potential. Most times the effects are gradual: not even felt until they become serious. Answering the following questions will give us a profile of the specific stresses you have faced in your lifetime, allowing us to better assess the challenges to your health potential.

Childhood History:
*Did you have any childhood illnesses?
*Did you have any serious falls (crib, bunk beds, trees, etc.)?
*Did you play youth sports?
*Did you take/use any drugs?
*Did you have any surgery?
*Were you involved in any car accidents as a child?
*Was there any prolonged use of medication such as antibiotics or an inhaler?
*Did you suffer any other traumas (physical or emotional)?
*Were you vaccinated?
*Were you under regular chiropractic care?

Adult (18 to Present):
*Do/did you smoke?
*Do/did you drink alcohol regularly?
*Have you had any accidents?
*Have you had any surgery?
*Do/did you play adult sports?
*Were you under regular chiropractic care?
*Describe your occupational stress (1=none, 10=extreme):		*Describe your personal stress:
*Describe your General Health:		*Describe your Diet:
*Describe your Exercise:		*Describe your Sleep:

Current Health Issues:
If you have no symptoms or complaints, and are here for a wellness visit, please indicate that here I'm interested in Chiropractic Wellness Services and skip to the Family Health Profile below. Others need to briefly describe the chief area of complaint, including the effect it has had on your life:

If you are currently experiencing pain, it is (check all that apply)... Sharp Dull Comes & Goes Travels Constant
Since the problem started, it is:
What makes it worse:
Yes, it interferes with (check all that apply)... Work Sleep Walking Sitting Hobbies Leisure
Other doctors seen for this condition:	Chiropractor Medical Doctor Other
Please check other symptoms you have had, even if they are unrelated to your current condition:	Headaches Pins and Needles in Arm Dizziness Numbness in Fingers Fatigue Sleeping Problems Diarrhea Cold Sweats Mood Swings Pins and Needles in Legs Loss of Smell Buzzing in Ears Numbness in Toes Depression Stiff Neck Constipation Light bothers Eyes Menstrual Pain	Fainting Back Pain Ringing in Ears Loss of Taste Irritability Cold Hands Fever Problem Urinating Menstrual Irregularity Neck Pain Loss of Balance Nervousness Upset Stomach Tension Cold Feet Hot Flashes Heartburn Ulcers
List any medications you are taking:

Family Health Profile:
At our office, we are not only interested in your health and well-being, but also and health and well-being of your family and loved ones. Please mention below any health conditions or concerns you may have about your:
	Children
	Spouse
	Mother
	Father
	Brothers
	Sisters
	Others
*Have you ever bought bottled water?
*Have you ever belonged to a health club?
*Have you ever consumed vitamins and/or supplements?

*The statements made on this form are accurate and true to the best of my recollection and I agree to allow this office to examine me for further evaluation.

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Bethel Park: 412-833-1990 North Side: 412-321-3213

New Patient Information

Your Health Profile

Childhood History:

Adult (18 to Present):

Current Health Issues:

Family Health Profile: