New Patient History Form

Patient History Form

Fill out the form carefully for registration
Patient Name*

First NameMiddle NameLast Name
How did you hear about our clinic?
If referred by someone, who referred you? If you just did a search what search engine did you use?
Birth Date*

MonthDayYear
Patient E-mail*
example@example.com, if no email use None@none.com
Cell Phone Number*

Area CodePhone
What type of work or home activity do you do most days?*
What physical activity do you do? (i.e. desk job- sit, travel a lot for work or pleasure, construction- bending lifting etc, stay at home Mom caring for children, etc.)
I understand and agree to authorize the doctors at Life Enhancing Wellness Centers, LLC and/or the properly trained staff to administer examination procedures and treatments, as deemed necessary at that time:
Signature*

Clear
Please take a pictue of your Driver's License and your health or auto insurance card if using them at our clinic for your treatment (if no insurance skip this). Take a picture of the front and back or scan if you have a scanner and upload those pictures below. We accept, Medicare and most Anthem BC/BS (but NOT Healthkeepers) and most Aetna Insurances.
Picture or pdf file of the Front of your insurance card

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picture or pdf file of the back of your insurance card

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picture or pdf file of your Driver's License

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Tell the Doctor about your past injuries.

Falls, crashes, beatings, broken bones, sprains, etc. from childhood to present, list them ALL here.
Past 'slip and falls'- Accidents
Date of Slip and Falls
2nd Slip or Fall accident
Date of this Slip and Falls
3rd slip and fall accident
Date of this Slip and Falls
Any additional information about your falls or daredevil antics that that you want to share.
slip and fall details
Auto Accidents, current and past

If your current complaint is from a recent (30 days or less or open legal case) auto accident list details in Additional Chief Complaints comments box above. List all PAST auto accidents here.
Most recent Auto Accident from your past that is NOT related to any current auto accident that you listed above in your "Current Complaint Box" if you current complaints are from or related to a recent auto crash, whether you were the driver or passenger.
Most recent auto accident
Any auto accident before the one listed above?
Auto Accident #2
Any other older auto accidents
Auto Accident #3
Additional auto accident comments, list dates and what was injured in each accident and if you still have problems from those accidents.
Auto accident details please list what accident date you are referring to if multiple accident date notations are being made.
Work Place Injuries

All workers comp cases and non-reported work injuries list here.
Most recent Work Injury from your past that is NOT related to any current workers compensation case or a new work injury that you listed above in your "Current Complaint Box" if you current complaints are from or related to a an injury that occurred while on the job. Like, "I was lifting a heavy box in the stock room and pulled my lower back and now it hurts.." etc. .
The most recent Work Place injury
Other workplace on the job injuries or accidents
Any prior work place injury
Other workplace injuries or accidents
Other Work Place injuries
Additional comments on workers comp injuries if any, list dates and details of each injury and what was hurting at the time and if it still bothers you.
Work place injury comments
Sports Injuries

From Little League to Professional athletics and everything in between.
Sports Injury. Again list here any OTHER sports injuries that you have had in the past that are different than this current injury if this current complaint is from a sports injury. Sports injury examples are, " I was jogging and twisted my knee or I got tackled in a backyard football game, I was playing college basketball and pulled my lower back, etc.". This box for all such PAST injuries that have NOT listed the "Main Complaint box" above.
Most recent Sports Injury
Next most recent sports injury
Next Sports Injury
Other Sports Injuries
Other Sports Injuries
Additional sports injury comments
Sport injury comments, give dates and basic details of each injury issue.

Patient History Form

What do you want the Doctor to help you with on your first visit?

Tell the Doctor about your past injuries.

Auto Accidents, current and past

Work Place Injuries

Sports Injuries

Medical History

Family History (Mother, Father, siblings

Lifestyle, Nutritional information