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:
_______________________