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New Patient Online Form

Call Us Today! (870) 932-5661 or text us at 870-761-5661

Call Now

About us
- About the Doctor
- Testimonials
Chiropractic Services
Patient Center
Resources
Contact
- Appointment Request

New Patient Online Form

CONFIDENTIAL HEALTH INFORMATION

Today’s Date (MM/DD/YYYY)

Whom may we thank for referring you?

Have you consulted a chiropractor before?

No Yes

When?

If so, whom?

Last Name*

Your Middle Name (or Initial)

First Name*

Birth Date (MM/DD/YYYY)

Age

Gender

Male Female

Marital Status

Married Single Divorced Widowed Seperated

Race

Ethnicity

Preferred Language

Your Social Security Number

Address

City

State/Province

ZIP/Postal Code

Home Phone

Cell Phone *

Email *

Emergency Contact

Emergency Contact’s Phone

Spouse’s Name

Child’s Name and Age

Your Occupation

Your Employer

Work Phone

May we contact you at work?

Yes No

Preferred method of contact?

Home Phone Cell Phone Work Phone Email

Address

City

State/Province

ZIP/Postal Code

Primary Care Provider’s Name

Insurance Carrier

Policy Number

Insured’s Last Name

Insured’s First Name

Insured’s Middle Name (or Initial)

Birth Date (MM/DD/YYYY)

Who carries this policy?

Self Spouse Parent

Insured’s Employer

Address

City

State/Province

ZIP/Postal Code

Employer’s Phone

1. The symptom(s) that have prompted me to seek care today include:

2. And are the result of (darken circle):

An accident or injury Work Auto Other

Other

An interest in:

Wellness Other

Other

3. Onset (When did you first notice your current symptoms?

4. Intensity (How extreme are your current symptoms?) 0 - 10

Absent - 1 Absent - 2 Absent - 3 Uncomfortable - 4 Uncomfortable - 5 Uncomfortable - 6 Uncomfortable - 7 Agonizing - 8 Agonizing - 9 Agonizing - 10

5. Duration and Timing (When did it start and how often do you feel it?)

Constant Comes and goes.

How Often?

6. Quality of symptoms (What does it feel like?)

Numbness Tingling Stiffness Dull Aching Cramps Nagging Sharp Burning Shooting Throbbing Stabbing Other

7. Location (Where does it hurt?) Circle the area(s) on the illustration.

"O" for current condition "X" for conditions experience in the past

8. Radiation (Does it affect other areas of your body? To what areas does the pain radiate, shoot or travel.)

9. Aggravating or relieving factors (What makes it better or worse, such as time of day, movements, certain activities, etc.)

What tends to worsen the problem?

What tends to lessen the problem?

10. Prior interventions (What have you done to relieve the symptoms?)

Prescription medication Over-the-counter drugs Homeopathic remedies Physical therapy Surgery Acupuncture Chiropractic Massage Ice Heat Other

Other

11. What else should Dr. Myshka know about your current condition?

12. How does your current condition interfere with your:

Work or career:

Recreational activities:

Household responsibilities:

Personal relationships:

13. Review of Systems
Chiropractic care focuses on the integrity of your nervous system, which controls and regulates your entire body. Please darken the circle beside any condition that you’ve
Had or currently Have and initial to the right.

a. Musculoskeletal

Osteoporosis

Had Have NONE

Knee injuries

Had Have NONE

Arthritis

Had Have NONE

Foot/ankle pain

Had Have NONE

Scoliosis

Had Have NONE

Shoulder problems

Had Have NONE

Neck pain

Had Have NONE

Elbow/wrist pain

Had Have NONE

Back problems

Had Have NONE

TMJ issues

Had Have NONE

Hip disorders

Had Have NONE

Poor posture

Had Have NONE

b. Neurological

Anxiety

Had Have NONE

Depression

Had Have NONE

Headache

Had Have NONE

Dizziness

Had Have NONE

Pins and needles

Had Have NONE

Numbness

Had Have NONE

c. Cardiovascular

High blood pressure

Had Have NONE

Low blood pressure

Had Have NONE

High cholesterol

Had Have NONE

Poor circulation

Had Have NONE

Angina

Had Have NONE

Excessive bruising

Had Have NONE

d. Respiratory

Asthma

Had Have NONE

Apnea

Had Have NONE

Emphysema

Had Have NONE

Hay fever

Had Have NONE

Shortness of breath

Had Have NONE

Pneumonia

Had Have NONE

e. Digestive

Anorexia/bulimia

Had Have NONE

Ulcer

Had Have NONE

Food sensitivities

Had Have NONE

Heartburn

Had Have NONE

Constipation

Had Have NONE

Diarrhea

Had Have NONE

f. Sensory

Blurred vision

Had Have NONE

Ringing in ears

Had Have NONE

Hearing loss

Had Have NONE

Chronic ear Infection

Had Have NONE

Loss of smell

Had Have NONE

Loss of taste

Had Have NONE

g. Skin

Skin cancer

Had Have NONE

Psoriasis

Had Have NONE

Eczema

Had Have NONE

Acne

Had Have NONE

Hair loss

Had Have NONE

Rash

Had Have NONE

h. Endocrine

Thyroid Issues

Had Have NONE

Immune disorders

Had Have NONE

Hypoglycemia

Had Have NONE

Frequent infection

Had Have NONE

Swollen glands

Had Have NONE

Low energy

Had Have NONE

i. Genitourinary

Kidney stones

Had Have NONE

Infertility

Had Have NONE

Bedwetting

Had Have NONE

Prostate issues

Had Have NONE

Erectile dysfunction

Had Have NONE

PMS symptoms

Had Have NONE

j. Constitutional

Fainting

Had Have NONE

Low libido

Had Have NONE

Poor appetite

Had Have NONE

Fatigue

Had Have NONE

Sudden weight gain/loss

Had Have NONE

Weakness

Had Have NONE

Past Personal, Family and Social History
Please identify your past health history, including accidents, injuries, illnesses and treatments. Please complete each section fully

14. Illnesses
Check the illnesses you have Had in the past or Have now.

AIDS

Had Have NONE

Alcoholism

Had Have NONE

Allergies

Had Have NONE

Arteriosclerosis

Had Have NONE

Cancer

Had Have NONE

Chicken pox

Had Have NONE

Diabetes

Had Have NONE

Epilepsy

Had Have NONE

Glaucoma

Had Have NONE

Goiter

Had Have NONE

Gout

Had Have NONE

Heart disease

Had Have NONE

Hepatitis

Had Have NONE

HIV Positive

Had Have NONE

Malaria

Had Have NONE

Measles

Had Have NONE

Multiple Sclerosis

Had Have NONE

Mumps

Had Have NONE

Polio

Had Have NONE

Rheumatic fever

Had Have NONE

Scarlet fever

Had Have NONE

Sexually transmitted disease

Had Have NONE

Stroke

Had Have NONE

Tuberculosis

Had Have NONE

Typhoid fever

Had Have NONE

Ulcer

Had Have NONE

Other:

Had Have

Other:

15. Operations
Surgical interventions, which may or may not have included hospitalization.

Operations

Appendix removal Bypass surgery Cancer Cosmetic surgery Eye surgery Hysterectomy Pacemaker Tonsillectomy Vasectomy Elective surgery: Spine Other:

Elective surgery:

Spine

Other:

16. Treatments

Check the ones you’ve received in the Past or are receiving Currently.

Acupuncture

Past Currently

Antibiotics

Past Currently

Birth control pills

Past Currently

Blood transfusions

Past Currently

Chemotherapy

Past Currently

Chiropractic care

Past Currently

Dialysis

Past Currently

Herbs

Past Currently

Homeopathy

Past Currently

Hormone replacement

Past Currently

Inhaler

Past Currently

Massage therapy

Past Currently

Physical therapy

Past Currently

Nutritional supplements:

Past Currently

Nutritional supplements List:

Medications (prescription and over-the-counter):

Past Currently

Medications (prescription and over-the-counter) List:

17. Injuries

Have you ever...

Had a fractured or broken bone Had a spine or nerve disorder Been knocked unconscious Been injured in an accident Used a crutch or other support Used neck or back bracing Received a tattoo Had a body piercing

18. Family History

Some health issues are hereditary. Tell Dr. Myshka about the health of your immediate family members.

Relative

Mother

Age (If living) Mother

State of health

Good Poor

Illnesses Mother

Age at death Mother

Cause of death

Natural Illness

Father

Age (If living) Father

State of health

Good Poor

Illnesses Father

Age at death Father

Cause of death

Natural Illness

Sister 1

Age (If living) Sister 1

State of health

Good Poor

Illnesses Sister 1

Age at death Sister 1

Cause of death

Natural Illness

Sister 2

Age (If living) Sister 2

State of health

Good Poor

Illnesses Sister 2

Age at death Sister 2

Cause of death

Natural Illness

Brother 1

Age (If living) Brother 1

State of health

Good Poor

Illnesses Brother 1

Age at death Brother 1

Cause of death

Natural Illness

Brother 2

Age (If living) Brother 2

State of health

Good Poor

Illnesses Brother 2

Age at death Brother 2

Cause of death

Natural Illness

19. Are there any other hereditary health issues that you know about?

20. Social History

Tell Dr. Myshka about your health habits and stress levels.

Alcohol use

Daily Weekly

Alcohol use How much?

Coffee use

Daily Weekly

Coffee use How much?

Tobacco use

Daily Weekly

Tobacco use How much?

Exercising

Daily Weekly

Exercising How much?

Pain relievers

Daily Weekly

Pain relievers How much?

Soft drinks

Daily Weekly

Soft drinks How much?

Water intake

Daily Weekly

Water intake How much?

Hobbies:

Prayer or meditation?

Yes No

Job pressure/stress?

Yes No

Financial peace?

Yes No

Vaccinated?

Yes No

Mercury fillings?

Yes No

Recreational drugs?

Yes No

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

Thank you. Your submission has been sent.

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Address

2817 S Caraway Rd Suite B,
Jonesboro, AR 72401

Phone

(870) 932-5661

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We look forward to hearing from you

Name*

Email *

Phone *

Comments

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

Thank you. Your submission has been sent.

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Monday

7:30 am - 5:30 pm

Tuesday

7:30 am - 5:30 pm

Wednesday

7:30 am - 5:30 pm

Thursday

7:30 am - 5:30 pm

Friday

Closed

Saturday

Closed

Sunday

Closed

2817 S Caraway Rd Suite B
Jonesboro,AR 72401

Call Us Today! (870) 932-5661
Or Text: (870) 761-5661

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