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(603) 224-3883
35 West Street, Concord, NH 03301
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New patient form
Home
About
About
Meet The Team
New Patient Registration
Services
Chiropractic Care
Chiropractic Treatment
Chiropractor Near Me
Spinal Manipulation
Non-Surgical Back Pain Treatment
Spinal Decompression
Shockwave
Injury-Specific Treatments
Auto Injury Treatment
X-Rays
Knee Pain Treatment
Neuropathy Treatment
Pain Management
Pinched Nerve Treatment
Sciatica Treatment
Scoliosis Treatment
Whiplash Treatment
Pain Management & Relief
Back Pain Treatment
Chronic Pain Treatment
Drug Free Pain Relief
Headache Treatment
Migraine Treatment
Natural Pain Relief
Neck Pain Treatment
Spine & Disc Treatments
Bulging Disc Treatment
Herniated Disc Treatment
Spinal Stenosis Treatment
Products
Contact
New patient form
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Date
Name
Home/Cell
Address
City
State
ZIP Code
DOB
Age
Email
Emergency Contact
Emergency Phone
Chief Complaint
Date of onset
Mechanism of injury:
Frequency of Discomfort
Radiation of Symptoms: Non-Radiating If Radiating, Where?
Rate your pain level (0-10 w/10 being the worst) Now
Rate your pain level (0-10 w/10 being the worst) at its Worse
Modifying Factors:
Relieved by:
Aggravated by:
Previous episodes
Yes
No
If yes, When?
Previous care / treatment
Second Complaint
Date of onset
Mechanism of injury:
Frequency/Quality:
Radiation of Symptoms: Non-Radiating Date of onset If Radiating, Where?
Rate your pain level (0-10 w/10 being the worst) Now
Rate your pain level (0-10 w/10 being the worst) at its Worse
Modifying Factors:
Relieved by:
Aggravated by:
Previous episodes: If YES When?
Previous care / treatment:
Recent Diagnostic Tests (MRI, Xray's, Cat scan)
Please state when and where
Third Complaint
Date of onset
Mechanism of injury:
Frequency/Quality
Radiation of Symptoms: Non-Radiating If Radiating, Where?
Rate your pain level (0-10 w/10 being the worst) Now
Rate your pain level (0-10 w/10 being the worst) at its Worse
Modifying Factors:
Relieved by:
Aggravated by:
Previous episodes: If YES When?
Previous care / treatment:
Musculoskeletal:
Do you have any implants, screws, or fusions in your spine or extremities. If yes Where
Neurological: Any loss of smell, vision, or hearing since the onset of your complaint(s) If YES, please explain
Head & ENT Complaints
Cardiovascular Disease
Respiratory Disease:
Gastrointestinal Disease
Genitourinary Disease:
Endocrine Disease
Please list any daily activities that have become difficult since the onset of above injuries
Social History:
Occupation
Social Habits:
Alcohol
Cigarettes
Recreational drugs
Exercise Habits:
Diagnostic Tests: MRI, Xray, Cat Scan
Please state where and when:
Do you have any Allergies/Sensitivities:
Any Surgeries
Date(s).
Past Illnesses:
Accidents:
Auto, Work Related, Falls
Medications:
Date of last physical:
Patient Goals:
Explain your personal goal for starting treatment
Is there anything else you want the doctor to know?
Patient Signature:
Date
If minor, parent or guardian signature:
Date
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