This new patient form collects information such as contact details, insurance, medical history, and current symptoms from a new patient of Pappas Chiropractic Center. Preliminary screening tests will be done to determine if chiropractic care is suitable, and if not, the patient will be referred to another physician. The form requests details on insurance, primary care physician, current and past medical conditions, current pain levels and locations, and authorizes the chiropractic center to file insurance claims and receive medical records from other providers.

1. Pappas Chiropractic Center
New Patient Form
Thank you for choosing our office. Preliminary Screening Tests will be performed to help
determine whether or not you are a candidate for Chiropractic care. If you are not a candidate
for Chiropractic treatment, we will try to assist you in locating the type of physician or specialist
we feel your condition requires.
Today’s Date: ___ ___ ____
Patient Name: _________________________________________
Address: ____________________________ _________________________________________________
Home Phone ____ _____ ______ Work Phone _____ ______ _____
Cell Phone _____ __________
Social Security _____ _____ _____ Birth Date ___ ____ ____ Age ______
Male ___ Female ____
Current Employer:
_____________________________________________________________________________________________
Name
address
Job Title/Description/Duties:
____________________________________________________________email____________________________
Emergency Contact: __________________________
Name
_________________
Phone Number
_________________
Relationship
Spouse/ Partner Name: _____________________Their Place of Employment: _____________________
Spouse/ Partner Cell Phone or Contact Phone: _______________________________________
-------------------------------------------------------------------------------------------------------------------------------------------Insurance: _______________________________ _________________________ _____________________
Name
Id Number
Group Number
Name Of Insured: ________________________
Birth Date of Insured: __________________
-------------------------------------------------------------------------------------------------------------------------------------------Primary Care Physician: ______________________________________________________ _________
Name
Address
Phone
May we send a copy of the initial findings to your primary doctor? ______________
Date of last physical: ___________
Are you presently under any other physician’s care? _________ Dr. Name ______________________
Are you currently seeking Holistic Primary Care Treatment? ________
Are you currently seeking (neuromusculoskeletal) Chiropractic Care ? __________

2. Medical History including any operations and approx. date
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Location and type of pain today (where does it hurt?)
____________________________________________________________________________________________
How did this Happen? ______________________________________________________________________
When? ___________________
has this happened before? _____________________
Have you lost any days from work? ________________ Dates: ________________________
Have you ever had Chiropractic Care? ______ If yes, what were you treated for? ______________
Name
to Treat
Medications: _________________________ ________________________
_________________________ ________________________
Do you have a pacemaker? ______________________
If yes, please notify Doctor.
_____________________________________________________________________________________________
Please check any of the following symptoms that you have now or have had:
__ Headaches
__ Inability to Control Bowel
__ Constipation
__ Fever
__ Inability to Control Urine
__ Prostate Trouble
__ Chest Pain
__ Sweats
__ Frequent Urination
__ Chills
__ Diarrhea
Other: ________________________________________
____________________________________________________________________________________
Please check any of the following diseases that you have now or have had:
__ Diabetes
__ Heart Disease __ Cancer
__ Tuberculosis
__ Arthritis
__ Epilepsy
__ Hypertension
__ Stroke
__ Asthma
Other: _________________________
-------------------------------------------------------------------------------------------------------------------------------For Women:
To the best of your knowledge, is there any chance that you are pregnant? _______
If pregnancy is a possibility, notify the doctor.
Date of your last Menstrual Period ___ ___ ___ Please sign: ___________________________
-------------------------------------------------------------------------------------------------------------------------------------------STATEMENT OF FINANCIAL RESPONSIBILITY:
I understand I am financially responsible for any balance. I hereby authorize Dr. R. Mark
Pappas to receive any information which may have been acquired by examination or
other means of my physical condition, and I hereby release them of any consequence
thereof. I hereby authorize release of information necessary to file claim with my
insurance company and assign benefits other wise payable to me, to the doctor, or
group indicated on the claim. A copy of this is as valid as the original.
Please sign here:
_______________________________________________
Date:
_______________________