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214-691-9355

Address
7015 Snider Plaza, Suite 225,
Dallas, TX 75205

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Home
Services
New Patient Center
About Us
Our Location
Spinal Decompression
Cold Laser Therapy
Community Content

Home

New Patient Forms

New Patient Forms

Welcome to our online Patient Intake Form. The information you fill in will be sent directly to our office, speeding up your office visit and allowing us to better serve you.

Who are you?

First Name

Last Name

About You

Address information.

Address Line 1

Address Line 2

City

State

Zip Code

Demographic information.

Date of Birth

Gender

Marital Status

Number of Children

Spouse's Name

Height and weight.

Height

Weight

Contact information.

Preferred Phone Number

Please select

Mobile Phone Home Phone Other

Emergency contact information.

Name

Phone

Relation To You

Insurance information.

Do you have Insurance?

Referral Information.

Referring Physician

Referring Patient

Are you working with an attorney?

How did you hear about us?

Reason For Visit

Reason for visit information.

What is the MAIN reason for this visit?

Date of scheduled appointment:

Approximate date this condition began (exact date not required):

What caused this condition:

What term(s) describes your discomfort best? Choose all that apply.

Aching

Yes No

Burning

Yes No

Deep

Yes No

Dull

Yes No

Intolerable

Yes No

Sharp

Yes No

Shooting

Yes No

Stabbing/Throbbing

Yes No

Stiffness

Yes No

Tightness

Yes No

Tingling

Yes No

Rate the severity of your discomfort at its worst, on a scale of 1-10 where 1 is the least severe and 10 is the most severe..

How often do you feel this discomfort?

How has this complaint changed since the onset?

What treatment, if any, have you received since the injury? Choose all that apply.

None

Yes No

Chiropractic care

Yes No

Massage

Yes No

Medical injection treatment

Yes No

Surgical treatment

Yes No

Over-the-counter medications

Yes No

Prescribed medications

Yes No

Natural or holistic treatment

Yes No

Acupuncture

Yes No

Physical therapy

Yes No

Other

Yes No

What aggravates this condition? Choose all that apply.

Almost any movement Athletic activity and/or exercise Bending Carrying or lifting Changing positions Coughing and/or sneezing Daily child or pet care Getting out of bed, chair or car Household chores (cleaning, cooking, etc.) Looking over shoulder Lying down, getting and staying asleep Pulling, pushing or reaching Raising arm(s) above shoulder(s) Self care (dressing, bathing, etc.) Sitting in car or chair Squatting or bending Standing Stress Walking or running Working at a desk/computer Yardwork Unknown Other

What improves this condition or gives you relief? Choose all that apply.

Nothing Chiropractic adjustment Prescription medications Cold packs Re-directs attention Exercise Rest Heat packs Stretching Massage Work Over-the-counter medications Physical therapy Other

Have other health care provider(s) performed tests related to this condition?

Yes No

Have you ever had any previous episodes of this condition?

Yes No

Do you have an additional condition?

Yes No

Current Health

Health Information

Other than the condition(s) already shared, do you have additional health concerns?

Muscles, Bones or Joints Nerves, Headaches, Dizziness, or Emotional Head, Eyes, Ears, Nose or Throat Heart, Blood Pressure, or Circulation Shortness of Breath, Coughing, Asthma or Lung Condition Stomach, Bowels or Digestive Conditions Genital, Bladder, or Urinary Conditions Diabetes, Thyroid or Glandular Conditions Skin or Bleeding Conditions Do you have any medication allergies?

*If you have answered yes to any of the above, please share this info with your doctor.

Personal and Family History

Have you had any surgical procedures?

Yes No

Are there any past illnesses or conditions we should be aware of?

Yes No

Do you have a past history of accidents or trauma?

Yes No

Are you presently taking any medication?

Yes No

Do you have a past family illness history, such as diabetes, cancer, hypertension, and progressive neurological diseases that we should be aware of?

Yes No

*If you have answered yes to any of the above, please share this info with your doctor.

Work Social Habits

Current work habits - Choose all that apply

Permanently fully disabled Permanently partially disabled Cannot work due to current condition Full-time (20-40+ hours/week) Part-time (1-19 hours/week) Retired Student Homemaker Unemployed

Personal social habits - Choose all that apply.

Smoke or use tobacco products Drink alcohol Drink caffeine Use recreational drugs Other, to be discussed with doctor

Present exercise habits - Choose all that apply.

No current exercises Exercises daily Exercises 3+ times per week Cannot return to exercise due to current condition Other, to be discussed with doctor

Diet and nutrition habits - Choose all that apply.

Vegan or vegetarian Daily supplements Other

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

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Location

Find us on the map

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Trinity Family Chiropractic, PC

Address

7015 Snider Plaza, Suite 225
Dallas, TX 75205, USA

Contact Information 214-691-9355

Contact Us Today

Name*

Email *

Phone *

Comments

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

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Office Hours

Monday

7:00 am - 6:00 pm

Tuesday

7:00 am - 6:00 pm

Wednesday

7:00 am - 6:00 pm

Thursday

7:00 am - 6:00 pm

Friday

7:00 am - 6:00 pm

Saturday

Closed

Sunday

Closed

Trinity Family Chiropractic

214-691-9355

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