Please complete the form below

Personal Information
Name *
Address *
Date of Birth *
Date of Birth
Sex *
Marital Status *
Are you a veteran or active military? *
How did you hear about our office (please check all that apply)? *
Have you been hospitalized within the past six months?
Have you had a complete spinal examination (including films) within the past year? *
Have you ever been to a chiropractor before? *
If you answered yes, how was your experience?
How do you prefer we contact you to schedule your consultation and examination? *
Is your reason/injury/condition related to an auto accident or work related injury? *
History of Complaint
Date of Onset (when did it begin) *
Date of Onset (when did it begin)
How often do you experience the pain? *
What time of day is the problem the worst? *
Does the pain/discomfort radiate into your extremities? *
Date of Onset
Date of Onset
How often do you experience the pain/discomfort?
What time of day is the problem the worst?
Does the pain/discomfort radiate into your extremities?
Date of Onset
Date of Onset
How often do you experience the pain/discomfort?
What time of day is the problem the worst?
Does the pain/discomfort radiate into your extremities?
In the past 6 months have you experienced any of the following health challenges? Please check all that apply.
Arms and Hands
Middle Back
Lower Back
If present check all that apply: "Pain is worse when"
Hips, Legs and Feet
Gastro-Intestinal Issues
Females Only Section
Ionizing radiation can be hazardous to an unborn child.
Are you trying to become pregnant?
If yes, have you had trouble conceiving?
Do you suffer with any of the following?
Check all that apply
Mental Health History
Have you been officially diagnosed with a mental health condition? *
Are you currently experiencing any of the following
Check all that apply
Have you attempted or have had thoughts about suicide?
Do you self harm?
Please identify how your current condition is affecting your ability to perform normal activities of daily living.
Changing Positions (example: sit to stand)
Climbing Stairs
Household Chores
Yard Work
Carrying Groceries
Caring for your pet(s)
Caring for Children
Operating a Vehicle
Using the Computer
Bathing Yourself
Dressing Yourself
Being Intimate/Sexual Activities
Past History
Have you suffered with this pain/symptom/condition/injury/illness in the past? *
Have you (in the past or currently) received care for this condition? *
If no surgeries in past say "none"
If no broken bones say "none"
If no major illnesses say "none"
Family History
Has anyone in your family suffer with or is currently suffering with similar condition(s)? *
If yes whom?
Are there any hereditary conditions that the doctor should be made aware of? *
Social History
Do you smoke (cigarettes, cigars, pipe)? *
Do you consume alcoholic beverages? *
Do you use marijuana? *
Do you use drugs recreationally (Example: cocaine, methamphetamines)? *
What position do you typically sleep in? *
List "none" if not currently taking any medications
If you wish for our office to verify your insurance benefits, please provide us with the following information.
Standard Waiver of Liability
I understand that I am financially responsible for any charges incurred at this office. For those patients using insurance, this would include co-pays, deductibles, and charges denied or not covered by my insurance company. My insurance company will review any and all documentation submitted by New Beginnings Chiropractic and I understand that final determination is based upon my insurance company’s medical guidelines. Insurance policy limitations are per individual insurance policy plans, as are co-payments, co-insurance, deductibles, referrals, etc. I understand this office agrees to notify me as soon as possible whether my care is approved or denied by my insurance company. I understand my initial visits may be denied and this may be beyond the office’s ability to notify me prior to rendering acute care, while waiting for insurance coverage approval. These charges will be my responsibility if denied by my insurance company. *
Informed Consent
Chiropractic is a art, science, and philosophy which concerns itself with the relationship between the spinal structure and the health of the central nervous system. Any disturbance to the CNS will create sickness and disease. One such disturbance to the nervous system is known as a vertebral subluxation. This occurs when one or more of the 24 vertebra in the spinal column become misaligned and/or do not move properlycreating nerve interference which may result in pain and dysfunction or may be entirely asymptomatic. In order to reduced or correct the vertebral subluxation the doctor will be using his/her hands to gently move the vertebra back in to a healthier position. At which time, you may feel a sense of movement of the vertebra and hear an audible “pop” or “click”. The sound created is completely natural and is merely a release of gas within the joints of the spine. Chiropractic care has been proven to be extremely safe and effective; however, it is not unusual to be sore after your first few specific chiropractic adjustments. Although rare, it is possible to suffer from other side effects; i.e. muscle spasms, stiffness, headaches, dizziness and in rare cases rib fracture. If at the beginning or during the course of care we encounter a non-chiropractic issue we will refer you out to the appropriate health care provider. I have the right, as a patient, to be informed about the condition and the recommended care to be provided so that I can make the decision whether or not to undergo chiropractic care after being advised of the known benefits, risks, and alternatives. All questions regarding the doctor’s objective to my care in this office has been answered to my complete satisfaction. *