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Contact
(562) 789 8661
New Patient Intake
Premiere Health Care
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New Patient Intake
Patient Information
What is your full name?
*
As it appears on your ID, insurance card or medical record
What is your date of birth?
*
What is your age?
What is your email address?
*
We'll keep you up to date with office news and announcements
What is your street address?
*
What is your city and state?
*
What is your postal or zip code?
*
What is your phone number?
*
Enter the best available phone number to reach you.
Who were you referred by?
Next - Insurance
Insurance
Will you be a medical insurance patient?
Yes
No
Please upload a picture of your insurance card
OR
provide complete insurance information below:
Please upload a picture of your insurance card:
What is the name of the primary insured ?
Is the name of the primary insured the same as the patient?
Yes
No
What is the name of the patient?
What is the name of your insurance company?
Please enter insurance customer service phone number
What is your insurance member ID number?
What is your group number?
Were you in an auto accident?
Yes
No
What was the date of your vehicle accident?
Format Example: Month/Day/Year
What is the name of your auto insurance?
What is the phone number of your auto insurance?
What is the name of the Auto Insurance contact person?
Insurance: What is the claim or policy number?
*
Please read the Auto Insurance legal notice and accept to continue.
I understand and agree that health/auto insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.
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Next - Medical History
Medical History
Have you ever been treated for any conditions in the last year?
Yes
No
Please describe the conditions you were treated for...
What is the date of your last physical exam?
Format Example: Month/Day/Year
What is the date of your last blood work?
Format Example: Month/Day/Year
Are you male or female?
Male
Female
Is there a chance that you may be pregnant?
Yes
No
This is to certify that to the best of my knowledge I am not pregnant and the above doctor and his/ her associates have my permission to perform an X-ray evaluation if needed. I am aware that X-ray, CT or other diagnostic studies can be hazardous to an unborn child.
Have you had X-rays taken?
Yes
No
Where were the X-rays taken & approximate date?
Are you currently taking medications?
Yes
No
What medications are you currently taking and for what conditions?
Please list dosage and amounts, etc. :
What vitamins, herbs or nutritional supplements do you currently take?
Please list for what condition, dosage and frequency
Have you
ever
broken any bones?
Yes
No
Briefly explain:
Have you
ever
been hospitalized?
Yes
No
Briefly explain:
Have you
ever
been in an auto accident?
Yes
No
Briefly explain:
Have you
ever
been struck unconscious?
Yes
No
Briefly explain:
Have you
ever
had surgery?
Yes
No
Briefly explain:
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Next - Lifestyle & Habits
Lifestyle & Habits
How often do you drink alcohol?
0
1
2
3
4
Please be honest. Your answers are secure.
How often do you intake caffeine?
0
1
2
3
4
Please be honest. Your answers are secure.
How often do you smoke or vape tobacco?
0
1
2
3
4
Please be honest. Your answers are secure.
How often do you use drugs (prescribed or recreational)?
0
1
2
3
4
Please be honest. Your answers are secure.
How often do you exercise?
0
1
2
3
4
Please be honest. Your answers are secure.
How many hours do you normally sleep?
0
1
2
3
4
Please be honest. Your answers are secure.
How much water do you drink daily?
0
1
2
3
4
Please be honest. Your answers are secure.
How often do you eat sugary/sweet food & snacks?
0
1
2
3
4
Please be honest. Your answers are secure.
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Next - Current Ailments
Current Ailments
What is the nature of your injury?
When was the date your symptoms appeared?
Format Example: Month/Day/Year
Have you had the same injury before?
Yes
No
Please name any other practitioners you've seen for your condition or injury.
Have you ever been under Acupuncture or Chiropractic care?
Acupuncture
Chiropractic
Briefly explain:
Do you currently or have you suffered from any of the following:
Allergies
Anemia
Arthritis
Asthma or Bronchitis
Back Pain
Breast Lump
Bone Density Loss
Bruise Easily
Cancer
Constipation
Depression
Diabetes
Digestion Problems
Dizziness
Tinnitus/Ears Ring
Unusual Fatigue
Frequent Urination
Headaches
High Blood Pressure
Hot Flashes
Irregular Heart Beat
Kidney Infection/Stones
Loss of Balance
Mid Back Pain
Neck Pain or Stiffness
Nosebleeds
Pacemaker
Poor Posture
Prostate Trouble
Sciatica
Sleep Problems/Insomnia
Spinal Curvatures
Stroke/Heart condition
Swelling of Ankles
Thyroid Condition
Ulcers
Do you experience pain or symptoms every day?
Yes
No
Briefly explain:
Do your symptoms interfere with daily life? Please explain briefly:
Are your symptoms worse during certain times of the day?
Yes
No
Briefly explain…
Do changes in weather affect your symptoms?
Yes
No
Briefly explain:
Do you wear foot orthopedics?
Yes
No
What activities aggravate your symptoms?
What area is bothering you? Please select your body's region.
Head
Neck
Shoulder (Right)
Shoulder (Left)
Elbow (Right)
Elbow (Left)
Wrist (Right)
Wrist (Left)
Hand (Right)
Hand (Left)
Hip (Right)
Hip (Left)
Knee (Right)
Knee (Left)
Ankle (Right)
Ankle (Left)
Foot (Right)
Foot (Left)
Leg (Right)
Leg (Left)
Back (Upper)
Back (Mid)
Back (Lower)
What type of pain is this causing you?
Pain
Loss of Use/Movement
Altered Sensation
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