Online Forms

New Patient Form


Welcome! If you are planning your first visit to Longview Chiropractic, we look forward to meeting you!

There are two ways you can fill out the new patient forms below:

1. Download, print, and manually fill it out.
or
2. Electronically fill in the new patient fields below.

If you do not already have AdobeReader® installed on your computer, Click Here to download it now.

  • Download the necessary form(s), print it out and fill in the required information.

  • Complete your forms and bring them in with you to your appointment
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Patient Information
Información del paciente

Date (Fecha):

Patient Name (Nombre del paciente):

Address (Dirección):

E-mail:

City (Ciudad):

State (Estado):

Zip (Código Postal):

Sex (Sexo):

Age (Edad):

Birthday (Fecha de nacimiento):

Patient Employer/School (Paciente Empleador / Escuela):

Occupation (Ocupación):

Employer/School Address (Dirección del empleador / escuela):

Employer/School Phone (Teléfono del empleador / escuela):

Spouse's Name (Nombre de la esposa):

Birthday (Fecha de nacimiento):

Spouse's Employer (Empleador del cónyuge):

Phone Numbers
Números de teléfono

Cellphone (Teléfono celular):

Home Phone (Teléfono de casa):

Best time to reach you (Mejor momento para contactarte):


IN CASE OF EMERGENCY, CONTACT (EN CASO DE EMERGENCIA, CONTACTO):

Name (Nombre):

Relationship (Relación):

Home Phone (Teléfono de casa):

Cellphone (Teléfono celular):

Accident Information
Informacion de accidentes

Is condition due to an accident? (Es esta condición debido a un accidente?):

Type of accident (Tipo de accidente):

To whom have you made a report of your accident? (A quién has hecho un informe de su accidente?):

Attorney Name (Nombre del abogado): (if applicable)

Patient Condition
Condición del paciente

Reason for Visit (Razón de la visita):

When did your symptoms appear? (¿Cuándo aparecen los síntomas?):

Is this condition getting progressively worse? (¿Esta condición esta empeorando progresivamente?):

Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain) (Califique la gravedad de su dolor en una escala de 1 (menos dolor) a 10 (dolor intenso)):

Type of pain (Tipo de dolor):

How often do you have this pain? (Con qué frecuencia tienes este dolor?):

Is it constant or does it come and go? (¿Es constante o va y viene?):

Does it interfere with your (Interfiere con su)

Activities or movements that are painful to perform (Actividades o movimientos que son dolorosos para realizar):

Health History
Historia de salud

What treatment have you already received for your condition? (¿Qué tratamiento ya recibió para su condición?):

Name and address of other doctor(s) who have treated you for your condition (Nombre y dirección del otro médico (s) que lo han tratado por su condición.):

Date of Last (Fecha de último):

Physical Exam (Examen físico):

Spinal Exam (Examen espinal):

Dental X-Ray (Radiografía dental):

Spinal X-Ray (Radiografía de columna):

Chest X-Ray (Radiografía de pecho):

MRI, CT-Scan, Bone Scan (Imagen de Resonancia Magnética, Tomografía computarizada, Gammagraffa ósea)

Blood Test (análisis de sangre):

Urine Test (Examen de orina):

Please choose on "Yes" or "No" to indicate if you have had any of the following (Coloque una marca en “Si” o “No” para indicar si usted ha tenido alguno de los siguientes):

AIDS/HIV

Alcoholism

Allergy Shots

Anemia

Anorexia

Appendicitis

Arthritis

Asthma

Bleeding Disorders

Breast Lump

Bronchitis

Bulimia

Cancer

Cataracts

Chemical Dependency

Chicken Pox

Diabetes

Emphysema

Epilepsy

Fractures

Glaucoma

Goiter

Gonorrhea

Gout

Heart Disease

Hepatitis

Hernia

Herniated Disk

Herpes

High Blood Pressure

High Cholesterol

Kidney Disease

Liver Disease

Measles

Migraine Headaches

Miscarriage

Mononucleosis

Multiple Sclerosis

Mumps

Osteoporosis

Pacemaker

Parkinson's Disease

Pinched Nerve

Pneumonia

Polio

Prostate Problem

Prosthesis

Psychiatric Care

Rheumatoid Arthritis

Rheumatic Fever

Scarlet Fever

Sexually Transmitted Disease

Stroke

Suicide Attempt

Thyroid Problems

Tonsilitis

Tuberculosis

Tumors, Growths

Typhoid Fever

Ulcers

Vaginal Infections

Whooping Cough

Other

Exercise

Work Activity

Habits

Are you pregnant?

Injuries/Surgeries you have had


Please list your injuries/surgeries

Medications
Medicamentos

Pharmacy Name (Nombre de farmacia):

Pharmacy Phone (Nombre de farmacia):

Allergies
Alergias

Vitamins / Herbs / Minerals
Vitaminas / Hierbas / Minerales

Roya1234 none 8:30am - 5:30pm 1:00pm - 5:30pm 8:30am - 5:30pm 1:00pm - 5:30pm 8:30am - 12:00pm By Appointment Closed chiropractor https://www.google.com/search?sxsrf=ALeKk0135_BnPYJQ1pFQyUXtjMZZtKORxg%3A1592246828217&source=hp&ei=LMLnXoHICu_P0PEPtfaEmA4&q=longview+chiropractic%2C+NC&oq=longview+chiropractic%2C+NC&gs_lcp=CgZwc3ktYWIQAzIGCAAQFhAeMgYIABAWEB46BAgjECc6BAgAEEM6BQgAEJECOgUIABCxAzoFCAAQgwE6AggAOgQIABAKOggIABAWEAoQHjoICCEQFhAdEB5Q7AdYyI0BYM-PAWgCcAB4AIABgwGIAZUUkgEEMjIuNZgBAKABAaoBB2d3cy13aXo&sclient=psy-ab&ved=0ahUKEwiBjtrUvYTqAhXvJzQIHTU7AeMQ4dUDCAk&uact=5#lrd=0x89ac5ee3db4d4de3:0xb061529ad4a07eca,1,,, # # https://www.google.com/maps/place/Longview+Chiropractic/@35.7787432,-78.6053941,15z/data=!4m12!1m6!3m5!1s0x0:0xb061529ad4a07eca!2sLongview+Chiropractic!8m2!3d35.7786416!4d-78.6054766!3m4!1s0x0:0xb061529ad4a07eca!8m2!3d35.7786416!4d-78.6054766