first page to np forms

Sorbera Dr. Steven Sorbera

FAMILY CHIROPRACTIC 1962 Old Route 200N

Duncansville, PA 16635

(814) 693-3730

Patient Name____________________________________________________________________ Date:________

(Last name) (First) (Middle In.)

Address:____________________________________ City:________________State:_____ Zip:______________

Home Phone: (_____)________________ Work Phone: (_____)________________ Cell: (_____)_____________

SSN:_________________________ Email: ______________________________ Sex: M F

Age:_____ Birthdate: _____________ Married Widowed Single Separated Divorced Minor

Children Names/Ages________________________________________________________________________________

Patient Employer/School______________________________________Occupation:_____________________________

Spouse’s Name: _____________________________________________Spouse’s Birthdate: ______________________

Spouse’s Employer: _________________________________________ Spouse’s Occupation:____________________

Women Only: Are you Pregnant? Yes No

Hobbies/Interests:___________________________________________________________________________________

Who may we thank for referring you?__________________________________________________________________

Do you have health insurance? Yes No Name of Ins. Company:____________________________________

Reason for Visit:____________________________________________________________________________________

When did this condition appear?_____________________

Is this condition getting progressively worse? Yes No Same

Mark an X on the picture where you experience any pain, numbness or tingling

Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe) ______

Type of pain: Sharp Dull Throbbing Burning Numbness

Aching Shooting Tingling Cramps Swelling

Stiffness Other

How often do you have this pain?______________________________________

Is it constant or does it come and go?__________________________________

Does it interfere with your: Work Sleep Daily Routine Recreation

Painful activities or movements: Sitting Standing Walking Bending Lying Down

Is this a result of an accident or injury? Yes No If yes, when?______________

What have you done for this condition in the past? Chiropractic Medication Surgery

Physical Therapy None Other____________________

Name and address of other doctor(s) who have treated you for this condition_________________________________

Over Please…

Please check (√) any CURRENT conditions. Mark (X) for any PAST conditions.

_____Numbness/Tingling/pain in (arms/hands/fingers) L R _____Numbness/Tingling/pain in (buttocks, thighs/legs/feet/toes) L R

_____Headaches/Migraines _____Back Stiffness/pain _____Blurred Vision _____Hip Pain L R

_____Fractured Bones _____Diabetes _____Lung Problems _____Arthritis

_____Swollen Painful Joints _____Cancer (type)________ _____Gall bladder problems _____Convulsions/Epilepsy

_____Anemia _____Double vision _____Loss of Smell _____Tremor

_____Pain w/cough/sneeze _____Loss of taste _____Sinus problems/Allergies _____chest pain

_____Heart problems _____Digestive problems _____Irritability/Mood swings _____Stroke

_____Prostate problems _____Loss of Balance _____Cold hands _____Kidney trouble

_____Dizziness/Vertigo _____Nervousness/Anxiety _____Recurring Infections _____Buzzing/ringing in ears

_____Fatigue _____Tension/Stress _____Hot flashes _____Depression

_____Colon problems _____Stomach upset _____Problems urinating _____Sleeping problems

_____Cold Feet _____Diarrhea/Constipation/Gas _____Menopause _____Bed Wetting

_____Foot Problems _____Jaw/TMJ Problems _____Respiratory Problems _____Asthma

_____Cold Sweats _____Heartburn/Reflux _____Neck Stiffness/Pain _____Light Sensitive Eyes

_____High Blood Pressure _____Ulcers _____Frequent Colds/Flu _____PMS

_____Thyroid Problems _____Hormonal Problems _____Skin Problems _____Herniated Disc

_____Other _________________________________________________________________________________

EXERCISE WORK ACTIVITY HABITS

None Types of Exercise: Sitting Smoking Packs/Day ___________

Moderate _______________ Standing Alcohol Drinks/Week __________

Daily _______________ Light Labor Coffee/Caffeine Cups/Day ____________

Heavy _______________ Heavy Labor High Stress Level Reason ______________

INJURIES/SURGERIES You have had throughout your life

Description Dates

Auto Accidents _______________________________________________ _________________________________

Falls _______________________________________________ _________________________________

Head Injuries _______________________________________________ _________________________________

Broken Bones _______________________________________________ _________________________________

Dislocations _______________________________________________ _________________________________

Surgeries _______________________________________________ _________________________________

	The above information is true and accurate to the best of my knowledge. I clearly understand and agree that all services rendered to me are charged directly to me and that I am directly responsible for payment. Patient or Guardian Signature:_____________________________________ Date: _____________