5661 Highway 11 E Ste 1 Piney Flats, TN 37686 4463

Call Us! (423) 538-4000

Piney Flats Chiropractic Center

Home
Meet the Team
New Patient Center
- Printable Intake Form
- Online Intake Form
Chiropractic Services
Testimonials
Contact Us

Online Intake Form

Online Intake Form

First Name

Last Name

Date

Email (Your email will NOT be shared with any third parties, and is used for occasional office announcements and promotions.)

Address

City

State

Zip Code

Telephone (Home)

Telephone Work

Referred By

Age

Birth Date

Number of Children

Occupation

Employer

Marital Status

Spouse's Name

Spouse's Occupation

Spouse's Employer

Spouse's Health Status

Emergency Contact

Phone

Nature of Injury

Automobile

Work

Other

Please Describe

Date of Injury

Date Symptoms Appeared

Have you ever had same condition?

No

Yes

If yes, when

List other practioners seen for this injury/condition

Have you ever been under chiropractic care?

No

Yes

If yes, please describe

Name of party responsible for payment

Phone

Do you have health insurance?

No

Yes

Name of company

Insurance company name

Contact Person

Phone

Claim #

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

No

Yes

If yes, please describe

Date of last physical exam

Is there a chance that you are pregnant?

No

Yes

Have you had X-rays taken?

No

Yes

If yes, where?

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

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

Broken bones?

No

Yes

Briefly explain

Been hospitalized?

No

Yes

Briefly Explain

Been in auto accident?

No

Yes

Briefly explain

Had Sprains/Strains?

No

Yes

Briefly explain

Been struck unconscious?

No

Yes

Briefly explain

Had surgery?

No

Yes

Briefly explain

Family members - Present and past health conditions (Example: heart disease, cancer, diabetes, arthritis, etc.)

Do you experience pain every day?

No

Yes

Do your symptoms interfere with daily life?

No

Ye

Does pain wake you up at night?

No

Yes

Are your symptoms worse during certain times of the day?

No

Y

Do changes in weather affect your symptoms?

No

Yes

Do you wear orthotics?

No

Yes

Do you take vitamin supplements?

No

Yes

What activities aggravate your symptoms?

Alcohol

No

Yes

Coffee

None

Light

Moderate

Heavy

Tobacco

None

Lightr

Moderate

Heavy

Drugs

None

Light

Moderate

Heavy

Exercise

n

Light

Moderate

Heavy

Sleep

No

Light

Modera

Heavy

Appetite

None

Light

Moderate

Heavy

Soft Drinks

None

Light

Moderate

Heavy

Water

None

Light

Moderate

Heavy

Salty Foods

None

Light

Moderate

Heavy

Sugary Foods

None

Light

Moder

Heavy

Artificial Sweeterners

None

Light

Moderate

Heavy

have you ever suffered from:

Alcoholism

Allergies

Anemia

Arteriosclerosis

Arthritis

Asthma

Back Pain

Breast Lump

Bronchitis

Bruise Easily

Cancer

Chest Pain

Cold Extremities

Constipation

Cramps

Depression

Diabetes

Digestion Problems

Dizziness

Ears Ring

Excessive Menstruation

Eye Pain or Difficulties

Fatigue

Frequent Urination

Headache

Hemorrhoids

High Blood Pressure

Hot Flashes

Irregular Heart Beat

Irregular Cycle

Kidney Infection

Kidney Stones

Loss of memory

Loss of balance

Loss of smell

Loss of taste

Lumps In Breast

Neck Pain or Stiffness

Nervousness

Nosebleeds

Pacemaker

Polio

Poor Posture

Prostate Trouble

Sciatica

Sexually Transmitted Infection

Shortness of breath

Sinus Infection

Sleep problems or Insomnia

Spinal Curvatures

Stroke

Swelling of ankles

Swollen Joints

Thyroid Condition

Tuberculosis

Ulcers

Varicose Veins

Other

Free Text

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

Thank you for contacting us.
We will get back to you as soon as possible.

Oops, there was an error sending your message.
Please try again later.

Browse Our Website

Home
Meet the Team
New Patient Center
Adjustments & Treatment
Testimonials
Contact Us

Contact Information

Phone: (423) 538-4000

Email: pfcc@drsheriwingate.com

Address: 5661 Highway 11 E Ste 1 Piney Flats, TN 37686 4463

Business Hours

Mon, Wed: 9:00 am - 6:00 pm
Tuesday: Appointment Only
Thursday: 2:00 pm - 6:00 pm
Friday: 9:00 am - 1:00 pm
Sat - Sun: Closed

Content, including images, displayed on this website is protected by copyright laws. Downloading, republication, retransmission or reproduction of content on this website is strictly prohibited. Terms of Use | Privacy Policy

Share by: