Advanced Medical & Wellness Center
Advanced Medical & Wellness Center

3060 Dayton Xenia Rd Suite # A, Beavercreek OH

937-427-2225 (BACK)

Advanced Medical & Wellness Center

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New Patient Form
(*) denotes required field

First & Last Name(*) Invalid Input
Middle initial Invalid Input
Nickname Invalid Input
Email(*) Invalid Input
Can we send emails
(appt info, announcements, text msg, etc.)(*)
Invalid Input
Address(*) Invalid Input
City(*) Invalid Input
State(*) Invalid Input
Zip(*) Invalid Input
Work phone (xxx-xxx-xxxx) Invalid Input
Home phone (xxx-xxx-xxxx) Invalid Input
Cell phone (xxx-xxx-xxxx) Invalid Input
Cell carrier Invalid Input
Date of birth(*) Invalid Input
Gender(*)
Invalid Input
Referred by Invalid Input
Race Invalid Input
Language Invalid Input
Prim. care physician Invalid Input
Prim. care physician ph# (xxx-xxx-xxxx) Invalid Input
Occupation Invalid Input
Employer Invalid Input
Marital status Invalid Input
Spouse/parents name Invalid Input
Spouse/parents occupation Invalid Input
Spouse/parents employer Invalid Input
Emerg. contact name Invalid Input
Emerg. contact ph#
(xxx-xxx-xxxx)		 Invalid Input
   
Injury type Invalid Input
Describe injury Invalid Input
Date of injury Invalid Input
Current symptoms Invalid Input
Date of symptoms Invalid Input
Ever had same condition(*)
Invalid Input
If have had same condition,
approximately when		 Invalid Input
Other practitioners seen for
your injury/condition 		Invalid Input
Previously been under
Chiropractic care(*)
Invalid Input
Describe any previous
Chiropractic care		 Invalid Input
Guarantor/Subscriber Invalid Input
Guarantor's phone# (xxx-xxx-xxxx) Invalid Input
Guarantor's employer Invalid Input
Guarantor's DOB Invalid Input
Guarantor's relationship
to patient		 Invalid Input
Do you have insurance(*)
Invalid Input
Claims mailing address Invalid Input
Insurance company Invalid Input
Ins. company ph# (xxx-xxx-xxxx) Invalid Input
Insurance policy# Invalid Input
Group number Invalid Input
Do you have secondary insurance(*)
Invalid Input
Secondary insurance company Invalid Input
2nd insurance ph# (xxx-xxx-xxxx) Invalid Input
Insurance policy# Invalid Input
Group number Invalid Input
Auto-accidents or
work injury;
Date of injury Invalid Input
Insurance company or
responsible party		 Invalid Input
Ins. contact person Invalid Input
Phone (xxx-xx-xxxx) Invalid Input
Claim# Invalid Input
Claims mailing address Invalid Input
   
Have you been treated for
any cond. in the last year(*)
Invalid Input
If treated, please describe. Invalid Input
Date of last physical exam Invalid Input
Any chance you're pregnant(*)
Invalid Input
Had an x-ray taken(*)
Invalid Input
If x-ray taken, when and where Invalid Input
List meds taking & cond.
(dosage & amounts)		 Invalid Input
Vitamins, minerals or herbs
taken? (for what condition, dosage & frequency)		 Invalid Input
Broken bones(*)
Invalid Input
Bones explain briefly Invalid Input
Been hospitalized(*)
Invalid Input
Hospital explain briefly Invalid Input
Been in an auto accident(*)
Invalid Input
Auto accident explain briefly Invalid Input
Had sprains or strains(*)
Invalid Input
Explain sprains or strains Invalid Input
Been struck unconscious(*)
Invalid Input
Explain unconscious event Invalid Input
Had surgery(*)
Invalid Input
Explain surgery event Invalid Input
   
Do you experience pain every day(*)
Invalid Input
Your symptoms interfere with
your daily life?(*)
Invalid Input
Pain wake you up at night(*)
Invalid Input
Your symptoms worse at
certain times of day(*)
Invalid Input
Changes in weather affect
symptoms?(*)
Invalid Input
Do you wear orthotics(*)
Invalid Input
Take vitamins supplements(*)
Invalid Input
Activities that aggravate
symptoms 		Invalid Input
Alcohol consumption(*) Invalid Input
Caffeine consumption(*) Invalid Input
Drug consumption(*) Invalid Input
Exercise(*) Invalid Input
Tobacco use(*) Invalid Input
If smoker how much Invalid Input
Seasonal allergies(*)
Invalid Input
Food allergies(*)
Invalid Input
Medication allergies(*)
Invalid Input
Briefly explain allergies Invalid Input
Family medical history
(i.e. heart disease, cancer,
diabetes,arthritis, etc.)		 Invalid Input
   
Ever suffered from?
Alcoholism(*)
Invalid Input
Anemia(*)
Invalid Input
Arteriosclerosis(*)
Invalid Input
Arthritis(*)
Invalid Input
Asthma(*)
Invalid Input
Back pain(*)
Invalid Input
Breast lump(*)
Invalid Input
Bronchitis(*)
Invalid Input
Bruise easily(*)
Invalid Input
Cancer(*)
Invalid Input
Chest pain Conditions(*)
Invalid Input
Cold extremities(*)
Invalid Input
Constipation(*)
Invalid Input
Cramps(*)
Invalid Input
Depression(*)
Invalid Input
Diabetes(*)
Invalid Input
Digestion problems(*)
Invalid Input
Dizziness(*)
Invalid Input
Ear rings(*)
Invalid Input
Excessive menstruation(*)
Invalid Input
Eye pain difficulties(*)
Invalid Input
Fatigue(*)
Invalid Input
Frequent urination(*)
Invalid Input
Headache(*)
Invalid Input
Hemorrhoids(*)
Invalid Input
High blood pressure(*)
Invalid Input
Hot flashes(*)
Invalid Input
Irregular heart beat(*)
Invalid Input
Irregular cycle(*)
Invalid Input
Kidney infection(*)
Invalid Input
Kidney stones(*)
Invalid Input
Loss of memory(*)
Invalid Input
Loss of balance(*)
Invalid Input
Loss of smell(*)
Invalid Input
Loss of taste(*)
Invalid Input
Neck pain or stiffness(*)
Invalid Input
Nervousness(*)
Invalid Input
Nose bleeds(*)
Invalid Input
Pacemaker(*)
Invalid Input
Polio(*)
Invalid Input
Poor Posture(*)
Invalid Input
Prostate trouble(*)
Invalid Input
Sciatica(*)
Invalid Input
Shortness of breath(*)
Invalid Input
Sinus infection(*)
Invalid Input
Sleep problems or insomnia(*)
Invalid Input
Spinal curvatures(*)
Invalid Input
Stroke(*)
Invalid Input
Swelling of ankles(*)
Invalid Input
Swollen joints(*)
Invalid Input
Thyroid condition(*)
Invalid Input
Tuberculosis(*)
Invalid Input
Ulcers(*)
Invalid Input
Varicose veins(*)
Invalid Input
Venereal disease(*)
Invalid Input
Other medical info. Invalid Input