New Patient Intake Patient Name Today's Date Home Address City State Zip Code Phone Cell Phone Your Email DOB Minor (Under 18)? YesNo Gender MaleFemale Last 4 digits of SSN Occupation Employer Marital Status SM Name of Spouse/Significant Other Have you seen a Chiropractor before? YesNo If yes, when? YOUR HEALTH SUMMARY Headache/MigrainesLights bother eyesHot flashesPin and Needles in armsMenstrual painHeartburnDizzinessFaintingUlcersNumbness in fingersBack painAllergies / Sinus ProblemsFatigueRinging in earsAsthma/Breathing ProblemSleeping problemsLoss of tasteDiarrheaIrritabilityConvulsionsCold sweatsCold handsFeverMood swingsWeight Loss / IncreasePins and needles in legsProblem urinatingNervousness / DepressionLoss of smellMenstrual irregularityLoose StoolsBuzzing in earsNeck painIndigestion/Stomach IssueNumbness in toesLoss of balanceHigh Blood Pressure (including with Meds)DepressionStomach UpsetStiff neckStress / TensionConstipationCold FeetSkin ProblemsEars Ringing / Hearing ProblemsHeart Problems (including Surgeries/Medications)Vision Problems Please list medications taken in the last 6 months This office conforms to the current HIPAA guidelines. You may request a copy of our HIPAA policy at the front desk. Please initial to indicate you have been made aware of its availability By checking this box I acknowledge that the statements made on this form are accurate to the best of my recollection and I agree to allow the healthcare providers in this office to examine me and provide care. (NOTE: This form will not be submitted unless this box is checked) Please sign the attached Privacy Health Information Sheet:https://texasattorneygeneral.gov/files/agency/hb300_auth_form.pdf Please upload the signed form: