San Jose Chiropractor Dr. Timothy Jennings' Clinic - The O'Connor Health Center 408-293-2225

Confidential New Patient Questionnaire

First
Last
Address
Apt. no.
City
State
Zip
Home phone
Office phone
Cell phone
E-mail
Marital:
Spouse
Age
Birthday	(mm-dd-yyyy)
Height	ft in.
Weight lbs.
Family Members Children or siblings:	Names age yrs. yrs. yrs. yrs.

Occupation
Employer
How were you referred to our clinic?
If you are experiencing any health problems, please list your concerns in order of severity (pain, symptoms, etc.)	Condition how long long
Doctors Seen For This Condition



This problem is

Do you ever experience these conditions while working? Yes No

If yes, explain what activities at work cause you to experience these conditions.

Are there any other incidences, or events, outside of work that may have caused these conditions?

Yes No

If yes, explain

If this is due to an injury or accident, what is the date of injury or accident (if known)?

Date (mm-dd-yyyy)

List any medications you are taking.

List any surgeries or hospitalizations and when.

Have you been treated for any health condition by a physician in the last year?

Yes No If yes, describe.

Have you been in any auto accidents in the last 12 months?

Yes No

When? (mm-dd-yyyy)

Have you had chiropractic care before?

Yes No If yes, list other chiropractor(s).


Insurance Coverage	Does your insurance policy cover chiropractic care?	Yes No Unsure
	Insured's Employer
	Insured's date of birth	(mm-dd-yyyy)

Female patients only.

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