Home
New Patient Center
About Us
- Meet the Doctor
Services
Testimonials
Contact Us
- Appointment Request
3D Spine Simulator
Blog
Community Content

Home
New Patient Center
About Us
- Meet the Doctor
Services
Testimonials
Contact Us
- Appointment Request
3D Spine Simulator
Blog
Community Content

(704) 210-8810

Home

New Patient Center

Online Forms

New Patient Form

New Patient Form

First Name*

Last Name*

Date

Email (Your email will NOT be shared with any third parties, and is used for occasional office announcements and promotions.) *

Location You Are Visiting

Address

City

State

Zip

Telephone (Home)

Telephone (Work)

Referred By

Age

Birth Date

Number of Children

Occupation

Employer

Marital Status

Spouse's Name

Spouse's Occupation

Spouse's Employer

Spouse's Health Status

Emergency Contact

Phone

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 other practioners seen for this injury/condition

Have you ever been under chiropractic care?

No Yes

If yes, please describe

Name of party responsible for payment

Phone

Do you have health insurance?

No Yes

Name of company

Insurance company name

Contact person

Phone

Claim #

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

No Yes

If yes, please describe

Date of last physical exam

Is there a chance that you are pregnant?

No Yes

Have you had X-rays taken?

No Yes

If Yes, where?

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

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

Broken bones?

No Yes

Briefly explain

Been hospitalized?

No Yes

Briefly explain

Been in auto accident?

No Yes

Briefly explain

Had Sprains/Strains?

No Yes

Briefly explain

Been struck unconscious?

No Yes

Briefly explain

Had surgery?

No Yes

Briefly explain

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

Do you experience pain every day?

No Yes

Do your symptoms interfere with daily life?

No Yes

Does pain wake you up at night?

No Yes

Are your symptoms worse during certain times of the day?

No Yes

Do changes in weather affect your symptoms?

No Yes

Do you wear orthotics?

No Yes

Do you take vitamin supplements?

No Yes

What activities aggravate your symptoms?

Alcohol

No Yes

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 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 Sexually Transmitted Infection Shortness of breath Sinus Infection Sleep problems or Insomnia Spinal Curvatures Stroke Swelling of ankles Swollen Joints Thyroid Condition Tuberculosis Ulcers Varicose Veins Other

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

Thank you. Your submission has been sent.

Error!

Locations

Find us on the map

--mi

Cleveland Location

Address

109 W Main St.
Cleveland, NC 27013

Contact Information +1 704-210-8810

-- mi Cleveland Location
-- mi Salisbury Location

Office Hours

Our Regular Schedule

Salisbury Office

Monday

9:00 am - 12:00 pm

2:00 pm - 5:00 pm

Tuesday

Closed

Wednesday

2:00 pm - 5:00 pm

Thursday

Closed

Friday

9:00 am - 12:00 pm

2:00 pm - 5:00 pm

Saturday

Closed

Sunday

Closed

Cleveland Office

Monday

Closed

Tuesday

1:30 pm - 5:00 pm

Wednesday

Closed

Thursday

1:30 pm - 5:00 pm

Friday

Closed

Saturday

Closed

Sunday

Closed

Admin Log In
Site Map

New Patient Form

Locations

Find us on the map

Office Hours

Our Regular Schedule

Salisbury Office

Cleveland Office

Follow Us