Lewis Chiropractic | New Patient Intake

This form takes approximately 10–15 minutes to complete.

Your information is private and used only to provide you with the best possible care.

About You

Basic information to create your patient file

First Name *

Last Name *

Date of Birth *

Sex *

Home Address *

City *

State *

Zip *

Phone *

Best time to reach you

Height & Weight (optional)

Emergency Contact & Employment

Who to contact and your work situation

Emergency Contact

Name *

Phone *

Relationship

Employment / Activity Status *

Occupation / Role *

Typical Work / Daily Duties *

How did you hear about us? *

Visit Purpose

Tell us about your main reason for coming in

Main reason for your visit *

Primary areas of concern * (select all that apply)

Since onset, the discomfort has been *

What would you like to be able to do that you can't do comfortably right now? *

Areas of Concern — History

Tell us about your discomfort in detail

History of This Condition

Approximate date this condition began *

How did this problem begin? *

What do you think caused this condition? *

Describe Your Discomfort

Quality of discomfort * (select all that apply)

Pain / discomfort intensity *

NoneModerateWorst

Does this affect your sleep? *

What Affects Your Discomfort

What makes your problem worse? * (select all that apply)

What makes your problem better? * (select all that apply)

How long can you comfortably stand? *

How long can you comfortably sit? *

Surgical History

Important for safe and effective treatment

Have you had any surgery to your spine? *

⚠ Spinal surgery — will be flagged in your clinical record

Spine surgery details

Have you had a hip or knee replacement, or hip/knee instability? *

⚠ Hip/knee replacement — will be flagged

Hip / knee details

Have you had any recent surgery to any area of your body? *

⚠ Recent surgery — will be flagged

Recent surgery details

Any other surgeries in your history? *

Medical History

Current health conditions and medications

Have you ever been diagnosed with diabetes? *

Have you ever been diagnosed with cancer? *

Cancer details

Have you ever been diagnosed with a stroke or TIA? *

Stroke / TIA details

Do you have a pacemaker or implanted cardiac device? *

Have you been diagnosed with osteoporosis?

Are you currently pregnant or possibly pregnant?

Additional medical conditions (select all that apply)

Current medications *

Medication allergies *

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Thank you, !

Your intake form has been received.

We'll call you as soon as possible to schedule your first appointment.

If you have any X-rays, MRI reports, or imaging studies of your spine, please bring them to your appointment.

Lewis Chiropractic · 480 S Broad St, Battle Mountain, NV · (775) 568-1891

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