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NEW PATIENT INTAKE FORM

Tap the button below to complete your new patient paperwork.

Please do this prior to your appointment in order to allow Dr. Kim time to review your information.

New Patient Paperwork

Personal Information

Date Today

First Name *

Middle Name

Last Name *

Address *

Address 2

City *

State *

Zip Code

Home Phone

Cell Phone

Work Phone

Email *

Date of birth

Age

Height

Weight

Driver's License #

Best time/place to contact you

Spouse/Guardian First Name

Spouse/Guardian Last Name

Live With

Please choose

Spouse
Parents
Children
Friends
Alone
No elements found. Consider changing the search query.
List is empty.

Marital Status

Please choose

Single
Married
Widowed
No elements found. Consider changing the search query.
List is empty.

Employer

Occupation

Hours/week

Retired?

Yes

No

Yes

No

Emergency contact

Emergency contact Phone

How did you hear about us?

WHAT BROUGHT YOU INTO THIS OFFICE:
If you have no symptoms or complaints and are here for Optimal Health & Wellness Services, please skip to the “General Health History”.

Health Concerns - Please list your health concerns according to their severity

1. Health Concern

Rate of severity

Rate of severity

1 = mild
2
3
4
5
6
7
8
9
10 = severe
No elements found. Consider changing the search query.
List is empty.

When did this episode start?

If you had this condition before, when?

Did the problem begin with an injury?

Yes

No

% of the time pain/symptom present

2. Health Concern

Rate of severity

Rate of severity

1 = mild
2
3
4
5
6
7
8
9
10 = severe
No elements found. Consider changing the search query.
List is empty.

When did this episode start?

If you had this condition before, when?

Did the problem begin with an injury?

Yes

No

% of the time pain/symptom present

3. Health Concern

Rate of severity

Rate of severity

1 = mild
2
3
4
5
6
7
2
9
10 = severe
No elements found. Consider changing the search query.
List is empty.

If you had this condition before, when?

When did this episode start?

Did the problem begin with an injury?

Yes

No

% of time pain/symptom present

Did your symptoms start suddenly or progressively?

What were you doing when your symptoms started?

Since it began, is it:

About the same?

Better?

Worse?

Provocation/Palliation

What makes it worse?

What makes it better?

Quality

How would you describe your symptoms? Dull? Sharp? Ache? Etc (multi line)

Region/Radiation

Where do you feel the symptoms? Does it radiate? (multi line)

What have you done to help this condition? Was it of benefit? (multi line)

Do you have a family history of this or similar symptoms? (multi line)

Other doctors you have seen for this condition:

Basic Chiropractor (focuses mainly on neck and back pain)

“Wellness” Chiropractor (focuses on health and well being as well as underlying cause of pain and health concerns)

Medical Doctor

Dentist

Other

Doctor's details

Name

Address

When did you see them?

What did they say wrong?

Did it help?

Yes

No

What did they do?

Please describe

Have you been "forced" or "felt the need" to make any "positive" changes in your life due to this pain, illness, condition, etc? (i.e., eat better, less alcohol or drugs, meditate or breathe more, less destructive sports, activities, etc.)

Yes

No

If yes, What?

Is this condition interfering with any of the following:

Work

Sleep

Daily routine

Sports/exercise

Other

If other, please explain

Aligned with Dr. Kim provides our patient form online so you may complete it in the convenience of your own home or office. When completed, you may fax us your printed and completed form or bring it with you to your appointment.

Personal Information

Date Today

First Name *

Middle Name

Last Name *

Address *

Address 2

City *

State *

Zip Code

Home Phone

Cell Phone

Work Phone

Email *

Date of birth

Age

Height

Weight

Driver's License #

Best time/place to contact you

Spouse/Guardian First Name

Spouse/Guardian Last Name

Live With

Please choose

Spouse
Parents
Children
Friends
Alone
No elements found. Consider changing the search query.
List is empty.

Marital Status

Please choose

Single
Married
Widowed
No elements found. Consider changing the search query.
List is empty.

Employer

Occupation

Hours/week

Retired?

Yes

No

Yes

No

Emergency contact

Emergency contact Phone

How did you hear about us?

WHAT BROUGHT YOU INTO THIS OFFICE:
If you have no symptoms or complaints and are here for Optimal Health & Wellness Services, please skip to the “General Health History”.

Health Concerns - Please list your health concerns according to their severity

1. Health Concern

Rate of severity

Rate of severity

1 = mild
2
3
4
5
6
7
8
9
10 = severe
No elements found. Consider changing the search query.
List is empty.

When did this episode start?

If you had this condition before, when?

Did the problem begin with an injury?

Yes

No

% of the time pain/symptom present

2. Health Concern

Rate of severity

Rate of severity

1 = mild
2
3
4
5
6
7
8
9
10 = severe
No elements found. Consider changing the search query.
List is empty.

When did this episode start?

If you had this condition before, when?

Did the problem begin with an injury?

Yes

No

% of the time pain/symptom present

3. Health Concern

Rate of severity

Rate of severity

1 = mild
2
3
4
5
6
7
2
9
10 = severe
No elements found. Consider changing the search query.
List is empty.

If you had this condition before, when?

When did this episode start?

Did the problem begin with an injury?

Yes

No

% of time pain/symptom present

Did your symptoms start suddenly or progressively?

What were you doing when your symptoms started?

Since it began, is it:

About the same?

Better?

Worse?

Provocation/Palliation

What makes it worse?

What makes it better?

Quality

How would you describe your symptoms? Dull? Sharp? Ache? Etc (multi line)

Region/Radiation

Where do you feel the symptoms? Does it radiate? (multi line)

What have you done to help this condition? Was it of benefit? (multi line)

Do you have a family history of this or similar symptoms? (multi line)

Other doctors you have seen for this condition:

Basic Chiropractor (focuses mainly on neck and back pain)

“Wellness” Chiropractor (focuses on health and well being as well as underlying cause of pain and health concerns)

Medical Doctor

Dentist

Other

Doctor's details

Name

Address

When did you see them?

What did they say wrong?

Did it help?

Yes

No

What did they do?

Please describe

Have you been "forced" or "felt the need" to make any "positive" changes in your life due to this pain, illness, condition, etc? (i.e., eat better, less alcohol or drugs, meditate or breathe more, less destructive sports, activities, etc.)

Yes

No

If yes, What?

Is this condition interfering with any of the following:

Work

Sleep

Daily routine

Sports/exercise

Other

If other, please explain

8039 Line Avenue, Suite C, Shreveport, LA 71106

318-423-7379

© 2024 All The Way Health - All Rights Reserved

Terms and Conditions

8039 Line Avenue, Suite C, Shreveport, LA 71106

318-423-7379

© 2024 All The Way Health - All Rights Reserved

8039 Line Avenue, Suite C, Shreveport, LA 71106

318-423-7379

© 2021 All The Way Health - All Rights Reserved

Website by Hemingway West