New Patient Health Inquiry

New Patient Health History Form

In order to provide you the best possible care, please complete this form and bring it to

your first appointment. All information is strictly CONFIDENTIAL.

Patient Data

First Name *

Last Name *

Date *

Email *

* Your email will NOT be shared with any 3d parties, and is used for occasional office announcements and promotions.

Patient Data

Street Address *

City *

State *

Country *

Postal Code *

Telephone (Work) *

Referred By *

Age *

Birth Date *

Social Security # *

Number of Children *

Occupation *

Employer *

Marital Status *

Spouse's Occupation *

Spouse's Name *

Spouse's Employer *

Spouse's Health Status *

Emergency Contact *

Phone number *

Current Complaints

Nature of Injury *

Automobile

Work

Other

Please describe the injury *

Date of Injury *

Date symptoms appeared *

Have you ever had same condition? *

Yes

No

If yes, when?

List of other practitioners seen for this injury/condition *

Have you ever been under chiropractic care? *

Yes

No

If yes, please describe

Insurance Information

Name of party responsible for payment *

Tel. *

Do you have health insurance? *

Yes

No

Name of company *

If an auto accident, please provide:

Insurance Company Name *

Contact Person *

Tel. Phone *

Claim # *

Signatures

Name of the insured *

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Patient’s signature and date *

Clear

Spouse’s or guardian’s signature and date *

Clear

Medical History

Have you been treated for any conditions in the last year? *

Yes

No

If yes, please describe it

Date of last physical exam

Is there a chance that you are pregnant? *

Yes

No

Have you had X-rays taken? *

Yes

No

If Yes, where?

What medications are you taking and for what conditions (Please list dosage and amounts, etc)l *

What vitamins, minerals, or herbs do you currently take? (Please list for what conditions, dosage, and frequency). *

Contact us today to get a

"New Client Discount!"

Send us a message to get answers to any of your questions & we’ll get back to you within 24-48 hours or as soon as possible.

Book Appointment

Call Now

Top Personalized Chiropractic Care in Tualatin

[email protected]

Quick Links

Home

About

Peptides

Service

Chiropractic

Rehabilitation

Massage

Contact

8157 SW Seneca Street Tualatin, OR 97062

(503) 612-9981

Terms & Conditions / Privacy Policy

© Copyright 2026. Dr. James Davison Chiropractic. All rights reserved.<script src="https://widgets.leadconnectorhq.com/loader.js" data-resources-url="https://widgets.leadconnectorhq.com/chat-widget/loader.js" data-widget-id="6a5fed6ec6e06ac8e824aa3d" data-source="WEB_USER"></script>

New Patient Health Inquiry

New Patient Health History Form

Patient Data

Patient Data

Current Complaints

Insurance Information

If an auto accident, please provide:

Signatures

Medical History

Have you ever:

Family History

Habits

Contact us today to get a

"New Client Discount!"

Quick Links

Service

Contact

Terms & Conditions / Privacy Policy