New Patient Questionnaire- Adult "*" indicates required fields Step 1 of 9 11% Patient InformationName* First Last Address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone:*Home Phone:Email:* Enter Email Confirm Email Date of Birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender:* Male Female Occupation:* Employer or School You Attend:* Marital Status:SingleMarriedPartnerSeparatedDivorcedWidowedSpouse/Partner's Name: How were you referred to our practice? Physcian Referral Friend/Relative Facebook Ad Internet Search Reputation/Word of Mouth Sign Wellness Presentation Website Other Name of Friend/Relative Who Referred You: Have you ever had chiropractic care before? Yes No If, so when was your last visit to the chiropractor? MM slash DD slash YYYY Did your previous chiropractor take spinal x-rays? Yes No If, so when was your last set of spinal x-rays? MM slash DD slash YYYY Reasons for Seeking CareWhat are your reasons for seeking care in our practice? Please check all that apply: Decreasing Current Pain Preventing Future Pain Improving Sleep Increasing Energy Levels Improving Immune System Help Managing Stress Laser Therapy Nutrition Recommendations Spinal Evaluation Improving Quality of Life Overall Wellness Decreasing Medication(s) Improving Posture Exercise Instruction Massage Therapy Other Patient ConditionWhat is Your Primary Health Complaint(s): Please describe what you are feeling:How long have you been experiencing your pain/symptoms? Days Weeks Months Years Are your symptom(s) getting worse, staying the same or getting better? Getting worse Staying the same Getting better No major symptoms Please describe your pain/symptom(s)? Please check all that apply: Achey Burning Cramping Dull Loss of Feeling Numbness Sharp Stiffness Swelling Throbbing Tingling Other None of the Above What have you tried to get rid of this complaint? Check All That Apply: Family Doctor Chiropractor Physical Therapy Orthopedic Doctor Neurologist Medication Emergency Room Heat Ice Rest Surgery Herbs/Vitamins Nutrition/Diet None of the Above How committed are you to getting this problem(s) fixed? Not Committed Somewhat Committed Very Committed Other Health ComplaintsPlease check all that you are currently experiencing or have experienced in the past 12 months. Allergies Ankle/Foot Pain Arm Numbness/Tingling Arm Pain Arthritis (other) Arthritis Spine Asthma Bulging Disc(s) Buttock Pain Carpal Tunnel Syndrome Degenerated Disc(s) Dizziness Frequent Colds/Flu Grating Noises Neck Headaches Herniated Disc(s) High Blood Pressure Irritability Knee Pain Lack of Energy Leg Numbness/Tingling Leg Pain Lower Back Pain Menstrual Difficulty Mid Back Pain Muscle Cramping Muscle Spasms Neck Pain Neck Stiffness Pinched Nerve Seizures Shoulder Blade Pain Shoulder Pain Shoulder Tension Sinus Problems Tailbone Pain Upper Back Pain Other None of the Above Conditions/Disorders/DiseasesPlease check all health conditions and/or complaints that you currently have or have had in the past. Anxiety Bleeding Disorder Cancer Depression Diabetes Emphysema/COPD Epilepsy Gout Heart Disease Hepatitis High Cholesterol High Blood Pressure Kidney Disease Lyme Disease Multiple Sclerosis Osteoporosis/Osteopenia Parkinson’s Prostate Difficulty Psychiatric/Emotional Rheumatoid Arthritis Sleep Difficulty Thyroid Problems Tumors/Growths Other None of the Above What type of cancer were you diagnosed with? What year were you diagnosed? MedicationsPlease check all conditions and symptoms that you are currently taking medications for. ADD/ADHD Allergies/Sinus Antibiotics Anti-Depressant Anxiety Arthritis Asthma Birth Control Blood Pressure Cholesterol Depression Diabetes Digestion Headaches Heart Muscle Relaxant Pain Prostate Sleep Aid Steroids Thyroid Ulcers Other I Take No Medications Please rate how the following affect your daily activities:Frequency of Pain:0- No Pain2- Intermittent Pain (10% of the day)4- Intermittent Pain (25% of the day)6- Occasional Pain (50% of the day)8-Frequent Pain (75% of the day)10-Constant Pain (100% of the day)Lifting:0- No Pain with Heavy Weight2- Intermittent Pain with Heavy Weight4- Increased Pain with Heavy Weight6- Increased Pain with Moderate Weight8- Increased Pain with Light Weight10- Increased Pain with Any WeightPain Intensity:0- No Pain2- Intermittent Pain4- Mild Pain6- Moderate Pain8- Severe Pain10- Worst Possible PainPersonal Care: (dressing, washing, etc.)0- No Pain (No Restrictions)2- Intermittent Pain (Some Restrictions)4- Mild Pain (Need To Go Slowly)6- Moderate Pain (Need Some Assistance)8- Strong Pain (Need 100% Assistance)10- Severe PainRecreation:0- Can Do All Activities2- Can Do All Activities4- Can Do Most Activities6- Can Do Some Activities8- Can Do A Few Activities10- Cannot Do Any ActivitiesSleeping:0- Perfect Sleep2- Intermittently Disturbed Sleep4- Mildly Disturbed Sleep6- Moderately Disturbed Sleep8- Greatly Disturbed Sleep10- Totally Disturbed SleepStanding:0- No Pain After Several Hours2- Increased Pain After Several Hours4- Increased Pain After 2 Hours6- Increased Pain After 1 Hour8- Increased Pain After 30 Minutes10- Increased Pain with Any StandingTravel: (driving, riding, etc.)0- No Pain on Long Trips2- Intermittent Pain on Long Trips4- Mild Pain on Long trips6- Moderate Pain on Long Trips8- Moderate Pain on Short Trips10- Severe Pain on Short TripsWalking:0- No Pain Any Distance2- Increased Pain After Long Distance4- Increased Pain After 1 Mile6- Increased Pain After Half of a Mile8- Increased Pain After Quarter of a Mile10- Increased Pain with All WalkingWork:0- Can Do Usual Work (Plus Unlimited Extra)2- Can Do Usual Work (No Extra Work)4- Can Do 75% of Usual Work6- Can Do 50% of Usual Work8- Can Do 25% of Usual Work10- Can Do 0% of Usual Work Trauma/Injuries/SurgeriesPlease List All That Apply:Have you ever had any broken bones or dislocations? Yes No If yes, please describe: Have you ever been involved in a motor vehicle collision? Yes No If yes, please list the date and describe: Have you ever experienced a head injury? Yes No If yes, please list the date and describe: Have you ever experienced a neck or back injury? Yes No If yes, please list the date and describe: Have you ever experienced any significant falls or other injuries not already mentioned? Yes No If yes, please list the date and describe: Have you had any surgeries? Yes No Please list all surgeries you have had: Have you ever had a concussion? Yes No Please describe circumstances: Do you ever have trouble with memory, recall or word finding? Yes No Do you lose your train of thought during conversations? Yes No Do you frequently forget where you put objects like keys or important papers? Yes No Does anyone in your family have or had Alzheimer's, ALS, or Dementia? Yes No Have you ever had a stroke, been diagnosed with Lyme Disease, Multiple Sclerosis or Parkinsons disease? Yes No Explain: Do you have trouble falling asleep or staying asleep? Yes No Do you have low energy levels? Yes No Do you take nutritional/vitamin supplements? Yes No Would you like us to provide nutritional/vitamin supplement recommendations to assist you in improving your health? Yes No Overall Health Related QuestionsDo you routinely exercise with moderate intensity more than 3 times per week? Yes No Do you smoke or use tobacco products? Yes No Do you have a history of diabetes? Yes No Do you have history of stroke? Yes No Do you have history of cancer? Yes No Are you overweight or obese? Yes No Do you currently have significant problems with depression or anxiety? Yes No Female OnlyAre you pregnant? Yes No Maybe X-ray/Imaging Studies Awareness StatementBy clicking the "I have read and accept the above terms." button. I am acknowledging that the above information is correct. I understand the hazardous effects of ionization to an unborn child, and I have conveyed my understanding of the risks associated with exposure to x-rays. After careful consideration I therefore, do hereby consent to have the diagnostic x-ray examination the doctor has deemed necessary in my case.X-ray/Imaging Studies Awareness Statement I have read and accept the above terms. I do not accept the above terms. Your Family Doctor's InformationName of Your Family Doctor: Health Insurance Information***Please fill this section out COMPLETELY if you have health insurance. If Member/Subscriber ID is not supplied we will not be able to verify your insurance.*** Do you have health insurance? Yes No Primary Insurance Company: Subscriber's Name: Subscriber's Employer: Member/Subscriber's ID: Group ID: Subscriber's Date of Birth: Month Day Year Customer Service Phone # (Located on Back of Insurance Card): Customer Service Phone # is located on the back of your health insurance card. Please DO NOT enter the # 1 at the beginning of the phone number.Address Where to Send Claims (Should Be Located on Back of Insurance Card): Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Address located on the back of your health insurance card. If no address is listed please use your home address.Do you have any of the following connected to your primary insurance? Flexible Spending Account (FSA) Health Reimbursement Account (HRA) Health Savings Account (HSA) Are you covered by an additional insurance company? Yes No Secondary Insurance Company: Subscriber's Name: Subscriber's Employer: Subscriber's ID: Group ID: Subscriber's Date of Birth:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Customer Service Phone # (Located on Back of Insurance Card): Customer Service Phone # is located on the back of your health insurance card. Please DO NOT enter the # 1 at the beginning of the phone number.Address Where to Send Claims (Should Be Located on Back of Insurance Card): Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Address located on the back of your health insurance card. Do you have any of the following connected to your secondary insurance? Flexible Spending Account (FSA) Health Reimbursement Account (HRA) Health Savings Account (HSA) Assignment, Release of Benefits and Guarantee of PaymentI acknowledge that I have had the opportunity to review Madeira Chiropractic’s "Notice of Privacy Practices" on the practice’s website. The Notice of Privacy Practices describes the types of uses and disclosures of protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Madeira Chiropractic The Notice of Privacy Practices is also provided on request at the main administration desk of the practice. This Notice of Privacy Practices describes my rights and Madeira Chiropractic’s duties with respect to my protected health information. Madeira Chiropractic reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy to be sent in the mail, email or asking for one at the time of my next appointment.Acceptance of Assignment, Release of Benefits and Guarantee of Payment* I have read and accept the above terms. I do not accept the above terms. Notice of Privacy PracticesI acknowledge that I have had the opportunity to review Madeira Chiropractic’s "Notice of Privacy Practices" on the practice’s website. The Notice of Privacy Practices describes the types of uses and disclosures of protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Madeira Chiropractic The Notice of Privacy Practices is also provided on request at the main administration desk of the practice. This Notice of Privacy Practices describes my rights and Madeira Chiropractic’s duties with respect to my protected health information. Madeira Chiropractic reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy to be sent in the mail, email or asking for one at the time of my next appointment.Acceptance of Notice of Privacy Practices* I have read and accept the above terms. I do not accept the above terms. Terms of Acceptance/Informed ConsentYou are the decision maker for your health care. Part of our role is to provide you with information to assist you in making informed choices. This process is often referred to as “informed consent” and involves your understanding and agreement regarding the care we recommend, the benefits and risks associated with the care, alternatives, and the potential effect on your health if you choose not to receive the care. We may conduct some diagnostic or examination procedures if indicated. Any examinations or tests conducted will be carefully performed but may be uncomfortable. Chiropractic care centrally involves what is known as a chiropractic adjustment. There may be additional supportive procedures or recommendations as well. When providing an adjustment, we use our hands or an instrument to reposition anatomical structures, such as vertebrae. Potential benefits of an adjustment include restoring normal joint motion, reducing swelling and inflammation in a joint, reducing and improving neurological functioning and overall well-being. It is important that you understand, as with all health care approaches, results are not guaranteed, and there is no promise to cure. As with all types of health care interventions, there are some risks to care, including, but not limited to: muscle spasms, aggravating and/or temporary increase in symptoms, lack of improvement of symptoms, burns and/or scarring from electrical stimulation and from hot or cold therapies, including but not limited to hot packs and ice, fractures (broken bones), disc injuries, stroke, dislocations, strains, and sprains. With respect to stroke, there is a rare but serious condition known as an “arterial dissection” that typically is caused by a tear in the inner layer of the artery that may cause the development of a thrombus (clot) with the potential to lead to a stroke. The best available scientific evidence supports the understanding that chiropractic adjustment does not cause a dissection in a normal, healthy artery. Disease processes, genetic disorders, medications, and vessel abnormalities may cause an artery to be more susceptible to dissection. Stroke caused by arterial dissections have been associated with over 72 everyday activities such as sneezing, driving, and playing tennis. Arterial dissections occur in 3-4 of every 100,000 people whether they are receiving health care or not. Patients who experience this condition often, but not always, present to their medical doctor or chiropractor with neck pain and headache. Unfortunately a percentage of these patients will experience a stroke. The reported association between chiropractic visits and stroke is exceedingly rare and is estimated to be related in one in one million to one in two million cervical adjustments. For comparison, the incidence of hospital admission attributed to aspirin use from major GI events of the entire (upper and lower) GI tract was 1219 events per one million persons per year and risk of death has been estimated as 104 per one million users. It is also important that you understand there are treatment options available for your condition other than chiropractic procedures. Likely, you have tried many of these approaches already. These options may include, but are not limited to: self-administered care, over-the-counter pain relievers, physical measures and rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. Lastly, you have the right to a second opinion and to secure other opinions about your circumstances and health care as you see fit. Acceptance of Terms of Acceptance/Informed Consent* I have read and accept the above terms. I do not accept the above terms. Consent to Treatment, Payment Guarantee, and Release of InformationI hereby consent to examination and all treatments of myself or my minor dependent(s) for whom I am responsible. I guarantee payment for all services rendered regardless of my results or whether my insurance company(s) contributes or does not contribute toward payment for my care or care of minor dependent(s). I authorize Madeira Chiropractic to release my health and personal information for the purposes of billing, insurance submission, doctor referrals, insurance requests, test results, governmental agencies, etc. as required by law and allowed by law. Patient agrees to pay all fees if it becomes necessary to enlist a collection agency or law firm to collect a past due balance. Patient agrees to be responsible for all costs of collection on unpaid balances including, but not limited to, 1.5% interest (18% annually), collection fees (up to 50%), court costs and reasonable attorney fees.Acceptance of Consent to Treatment, Payment Guarantee, and Release of Information* I have read and accept the above terms. I do not accept the above terms. reCAPTCHACommentsThis field is for validation purposes and should be left unchanged.