Patient Intake FormFirst NameLast NameDate of BirthPhone/MobileEmailGender– Select –MaleFemaleOtherAge0Ethnicity– Select –American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhiteOtherSocial Security# Marital Status– Select –SingleMarriedDivorcedWidowedAddressAddress Line 1Address Line 2CityStateZip CodeCountrySelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweInsurance companyID#Group#Where / Who did you hear about us from?– Select –GoogleZocdocFriend / Family member refersOtherOccupation and weekly hours you workEmergency Contact’s Name Emergency Contact’s PhoneQuestionaire about Patient HistoryYesNoNot SureHave you had acupuncture beforeHave you had chiropractic beforeHave you had physical therapy beforeAre you currently pregnant? HIV positive? Hepatitis Positive?Chief Complain 1– Select –Neck pain Jaw pain/tightness (TMJ)Shoulder pain Arm painElbow painWrist painHand (joint) pain Upper back pain Middle back pain Lower back pain Tailbone pain Hip painKnee pain Leg pain Ankle painFoot pain Heel pain Swelling / Edema InsomniaTiredness / Fatigue Anxiety / DepressionHeadache / MigraineDizzinessBell’s PalsyAcneConstipation Nausea and VomitingDigestive disorders Weight management Irregular menstrual cycle Menstrual pain Infertility Women’s healthMenstrual treatmentHormonal inbalanceNot ListedChief Complain 2– Select –Neck pain Jaw pain/tightness (TMJ)Shoulder pain Arm painElbow painWrist painHand (joint) pain Upper back pain Middle back pain Lower back pain Tailbone pain Hip painKnee pain Leg pain Ankle painFoot pain Heel pain Swelling / Edema InsomniaTiredness / Fatigue Anxiety / DepressionHeadache / MigraineDizzinessBell’s PalsyAcneConstipation Nausea and VomitingDigestive disorders Weight management Irregular menstrual cycle Menstrual pain Infertility Women’s healthMenstrual treatmentHormonal inbalanceNot ListedChief Complain 3– Select –Neck pain Jaw pain/tightness (TMJ)Shoulder pain Arm painElbow painWrist painHand (joint) pain Upper back pain Middle back pain Lower back pain Tailbone pain Hip painKnee pain Leg pain Ankle painFoot pain Heel pain Swelling / Edema InsomniaTiredness / Fatigue Anxiety / DepressionHeadache / MigraineDizzinessBell’s PalsyAcneConstipation Nausea and VomitingDigestive disorders Weight management Irregular menstrual cycle Menstrual pain Infertility Women’s healthMenstrual treatmentHormonal inbalanceNot ListedComplaints that are not listed above (if any)Insurance Card UploadUpload the front & back of your insurance card.Upload the front of Insurance cardChoose File Upload the back of Insurance cardChoose File ID Card UploadUpload the front of your IDUpload the front of ID CardChoose File Save Form & Submit LaterSubmit Intake Form