New Patient Forms

Port St Lucie Chiropractor, Raymond Sykes, DC >>>

Welcome To Our New Patient Forms Section

These are inline forms which simply means each question will follow one after the other. The forms are not very pretty, but it is easier for some people to read and follow line by line down the page. Please fill in an answer to each question. If the answer does not apply to you, simply type in n/a or not applicable.

When you are finished with each form, click on the submit button and your form will be received by the office and the doctor will be prepared when you arrive.

Thank you in advance for being thorough and helping us help you. We look forward to seeing in the office.

This Form is What Dr. Sykes Calls, “The Chief Complaint Form”

List your complaints in the order of severity. Fill out only the portion of the form that applies to you. Thank you.

Form #3 – History on Your Current Symptoms and Complaint

This is a short form which may give us more insight on your current symptoms. We know these forms seem tedious, but they are really an important part of Dr. Sykes’ initial examination when you are in the office. Thank you again, for help us, help you.

History of Your Current Complaint - Form #3

This form may tell even more about your current complaint and give us more insight into any effects of your past history on this complaint.

Name
Date
How Did The Complaint You Have Now Start?
PAST HISTORY - Have you ever had similar complaints? If yes, please explain: Give date. How were you treated? Where and by whom? What was the outcome of your treatment? When was the last time you felt this complaint?
Have You Ever Been Hospitalized? When and Why?
Do You Have Any Bumps, Lumps, Cuts, Bruises, or Scars? If yes, where are they located?
Do You Wear Braces or Lifts?
Are You Taking Any Medicines and/or Supplements? Please List Them Here (include the dosage of the medicine) and How Often You Take Them?
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General Health Review – Form #4

This form is brief and will provide Dr. Sykes with an understanding of your overall health and family health history. Thank you for your patience.

Health Review - Form #4

This is the history of your health in general and not necessarily related to your current symptoms.

Name
Date
Serious Illnesses: (Please List)
When The Illness(es) Occurred
Treatment of The Illness(es)
Past Injuries:
When the Injuries Occurred:
Treatment for the Injuries
Past Surgeries
When Were Those Surgeries
Past Fractures
When Did Those Fractures Occur
Medications
Allergies to Food or Drugs
Nutritional Supplements
Social History: Alcohol Consumption
Social History: Smoke
Social History: Exercise Regularly
Work Requirements?
Hobbies?
Review of Symptoms: Answer These Yes or No
Swelling
Dizziness or Fainting Spells
Convulsions
General Prolonged Fatigue
Female Problems
Breast Soreness or Lumps
High Blood Pressure
Excessive Weight Loss/Gain
Digestive or Stomach Problems
Sinus or Allergy Problems
Are You Pregnant?
Headaches
Eyes/Ears/Nose/Throat/Mouth/Jaw
Diabetes
Arthritis
Skin Condition
Heart Condition/Stroke
Blood disorders
Cancer
Breathing/Respiratory Condition
Liver/Kidney/Bladder/Bowel Problems
Have You Had a Fever
Family History: Mother's General Health
Mother Deceased Age:
Mother Cause of Death:
Family History: Father's General Health
Father Deceased Age:
Father Cause of Death:
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Financial and Insurance Information – Form #5

We accept most major health insurance carriers as well as Medicare and Medicaid. This form will cover the necessary financial arrangements of your visit. You will be asked to take care of this final form when you come into the office. In addition, payment for services rendered will be expected unless other arrangements are made at the time of your visit.

pediatric chiropractic