Convenient Online Paperwork Form

Filling out our new patient paperwork in advance has three benefits! First, you can do it at a convenient time from home or work. Second, there’s no need to arrive early. Third, we can review the material in advance to determine the best and most thorough way to examine and treat you.

Name

First Name

Last Name

Date of Birth

YYYY

Mailing Address

Preferred Contact Number

(###)

###

####

Occupation (and for how long)

Who referred you to our practice?

Please describe what kind of trouble you're having:

How long have you suffered from this problem?

Do you remember how it started?

If yes, please describe here:

What's the pattern of this problem:

Constant

Off & On

Daily

Weekly

Monthly

What have you tried that hasn't worked so far?

When it's at its worst, how does it make you feel?

Does it interfere with any of the following:

Work

Family

Hobbies

Other

What makes it worse?

Does handling this problem cause stress for you?

How much older does it make you feel?

What has given you temporary relief?

What effect does it have on your other body functions (if any):

On a scale of 1-10, rate your commitment to solving this problem:

Have you ever been knocked unconscious or experienced a concussion?

What is your primary sleep position?

If you're on any type of medication, please list it here:

Include over-the-counter meds as well...

Please list any surgeries, including dental, that you've had:

(For example: Tonsils, adenoids, wisdom teeth, appendix ,gallbladder, orthopedic, etc)

On a scale of 1-10, how would you rate your quality of life:

On a scale of 1-10, how would you rate your level of health?

Please describe the result you're hoping to achieve:

If you have any other health goals/concerns, please describe them:

Who is your current primary care physician?

Have you experienced a fever or symptoms of an upper respiratory illness (chest congestion, difficulty breathing, cough, etc) within the past 14 days?