Priestley Chiropractic
81 Conklin Street
Farmingdale, NY 11735
(516) 752-1007
walter@priestleychiro.com

Thank you for choosing Priestley Chiropractic! We are looking forward to helping you with your current condition and getting you back on the road to wellness! Please fill out our New Patient Intake Form prior to your initial visit with us.

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Priestley Chiropractic
81 Conklin Street
Farmingdale, NY 11735
(516) 752-1007
walter@priestleychiro.com
First Name
Last Name
Address
City
Zip Code
Home Phone
Cell Phone
Work Phone
Email
Gender
Date of Birth
Birthdate
Height
Weight
Shoe Size
Marital Status
Spouse
Num. of Children
Emergency Contact
Relationship
Phone
Priestley Chiropractic
81 Conklin Street
Farmingdale, NY 11735
(516) 752-1007
walter@priestleychiro.com
How did you hear about us?
Family Physician
Date of Last Visit
Work Status
Occupation
Have you missed work due to this complaint?
Missed work start date
Return or anticipated return date
Insurance Coverage

Primary
Company
Policy #
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Who Carries this Policy?
Insured's Name
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Secondary
Company
Policy #
Group #
Who Carries this Policy?
Insured's Name
Insurance customer service or Provider services Phone Number
Priestley Chiropractic
81 Conklin Street
Farmingdale, NY 11735
(516) 752-1007
walter@priestleychiro.com
The symptoms that have prompted you to seek care today include:
Have you seen other doctor(s) for this condition?
Prior Interventions
What is the condition related to?
When did your problem first start?
Have you had this condition before?
Does the pain radiate or travel to other parts of the body?
Priestley Chiropractic
81 Conklin Street
Farmingdale, NY 11735
(516) 752-1007
walter@priestleychiro.com
Does anyone from your family suffer from the same condition?
What makes the condition worse?
What makes the condition better?
Does this condition affect employment?
Does this condition affect recreation?
Does this condition affect household?
Does this condition affect personal?
Does this condition affect sleep?
Priestley Chiropractic
81 Conklin Street
Farmingdale, NY 11735
(516) 752-1007
walter@priestleychiro.com
What else should we know about your current condition?
Rate the severity of your pain at its worst

No Pain
Excruciating Pain
Pain Duration
Current Medications
Supplements
Sleep Position
Hours of sleep per night (1-24)
Have you had any X-rays or MRI's in the last six months?
I realize that x ray examinations may be hazardous to an unborn child. I certify to the best of my knowledge I am not pregnant.
Last Cycle:
Priestley Chiropractic
81 Conklin Street
Farmingdale, NY 11735
(516) 752-1007
walter@priestleychiro.com
Type of Pain
Front Head

Type of Pain
Front Face

Type of Pain
Front Left Jaw

Type of Pain
Front Right Jaw

Type of Pain
Front Right Neck

Type of Pain
Front Left Neck

Type of Pain
Front Left Chest

Type of Pain
Front Right Chest

Type of Pain
Front Right Ribs

Type of Pain
Front Left Ribs

Type of Pain
Front Abdomen

Type of Pain
Front Pelvis

Type of Pain
Front Right Hip

Type of Pain
Front Left Hip

Type of Pain
Front Right Thigh

Type of Pain
Front Left Thigh

Type of Pain
Front Right Knee

Type of Pain
Front Left Knee

Type of Pain
Front Right Lower Leg

Type of Pain
Front Left Lower Leg

Type of Pain
Front Right Ankle

Type of Pain
Front Left Ankle

Type of Pain
Top of Right Foot

Please specify specific areas

Type of Pain
Top of Left Foot

Please specify specific areas

Type of Pain
Front Right Shoulder

Type of Pain
Front Left Shoulder

Type of Pain
Front Right Upper Arm

Type of Pain
Front Left Upper Arm

Type of Pain
Front Right Elbow

Type of Pain
Front Left Elbow

Type of Pain
Front Right Forearm

Type of Pain
Front Left Forearm

Type of Pain
Front Right Hand

Please specify specific areas

Type of Pain
Front Left Hand

Please specify specific areas

Type of Pain
Front Right Wrist

Type of Pain
Front Left Wrist

Type of Pain
Back of Head

Type of Pain
Back Right Neck

Type of Pain
Back Left Neck

Type of Pain
Upper Back

Type of Pain
Back Right Shoulder

Type of Pain
Back Left Shoulder

Type of Pain
Mid-Back

Type of Pain
Back Right Ribs

Type of Pain
Back Left Ribs

Type of Pain
Lower Back

Type of Pain
Back Right Hip

Type of Pain
Back Left Hip

Type of Pain
Back Right Glute

Type of Pain
Back left Glute

Type of Pain
Back Right Thigh

Type of Pain
Back Left Thigh

Type of Pain
Back Right Knee

Type of Pain
Back Left Knee

Type of Pain
Back Right Lower Leg

Type of Pain
Back Left Lower Leg

Type of Pain
Back Right Ankle

Type of Pain
Back Left Ankle

Type of Pain
Bottom of Right Foot

Please specify specific areas

Type of Pain
Bottom of Left Foot

Please specify specific areas

Type of Pain
Back Right Upper Arm

Type of Pain
Back Left Upper Arm

Type of Pain
Back Right Elbow

Type of Pain
Back Left Elbow

Type of Pain
Back Right Forearm

Type of Pain
Back Left Forearm

Type of Pain
Back Right Hand

Please specify specific areas

Type of Pain
Back Left Hand

Please specify specific areas

Type of Pain
Back Right Wrist

Type of Pain
Back Left Wrist

Priestley Chiropractic
81 Conklin Street
Farmingdale, NY 11735
(516) 752-1007
walter@priestleychiro.com
Select options below indicating age at diagnosis and other relevant details.
Musculoskeletal
Neurological
Cardiovascular
Respiratory
Digestive
Priestley Chiropractic
81 Conklin Street
Farmingdale, NY 11735
(516) 752-1007
walter@priestleychiro.com
Sensory
Integumentary
Endocrine
Genitourinary
General
Priestley Chiropractic
81 Conklin Street
Farmingdale, NY 11735
(516) 752-1007
walter@priestleychiro.com
Personal Illness History
Surgery/Trauma History
Priestley Chiropractic
81 Conklin Street
Farmingdale, NY 11735
(516) 752-1007
walter@priestleychiro.com
Social History

Priestley Chiropractic
81 Conklin Street
Farmingdale, NY 11735
(516) 752-1007
walter@priestleychiro.com
Please read the following carefully before signing.

Informed Consent to Chiropractic Treatment

 

The nature of chiropractic treatment


The doctor will use his/her hands or a mechanical device in order to move your joints.  You may feel a click or pop, such as the noise when a knuckle is cracked, and you may feel movement of the joint.  Various ancillary procedures, such as cold therapy, mechanical traction, manual therapy and rehabilitative exercises may also be used. Healing occurs over the course of time, unlike drugs, which may have an immediate effect on your symptoms. Please understand that in order to have an effective change in your condition, it will likely take repetition over several weeks. Similar to proving your level of fitness or losing weight, consistent effort and follow through is necessary on the patient's part.

 

Possible Risks:

 

As with any health care procedure, complications are possible following a chiropractic manipulation.  Complications could include fractures of bone, muscular strain, ligamentous sprain, dislocations of joints, or injury to intervertebral discs, nerves or spinal cord.  Cerebrovascular injury or stroke could occur upon severe injury to arteries of the neck.  A minority of patients may notice stiffness or soreness after the first few days of treatment.  The ancillary procedures could produce skin irritation, burns or minor complications.

 

Probability of risks occurring:

 

The risks of complications due to chiropractic treatment have been described as rare, about as often as complications are seen from the taking of a single aspirin tablet.  The risk of cerebrovascular injury or stroke, has been estimated at one in one million to one in twenty million, and can be even further reduced by screening procedures.  The probability of adverse reaction due to ancillary procedures is also considered rare.

 

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Today's Date: 14 Dec 2018