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M T & F: 9am - 5pm, W & Th: 1pm - 6pm

NEW PATIENT INTAKE

Patient Health History

*All information will be kept strictly confidential. Your responses will allow us to get a more complete picture of your health, uncover contributing factors to your chief complaint(s) and advise you in your health goals. Thank you for investing in your health. We look forward to supporting you!

Address

Married? YesNo

Children? YesNo

Children's Names and Ages:

Please mark all conditions, past and present, even if they are only occasional:

Neck Pain PastPresent
Arm pain PastPresent
Elbow pain PastPresent
Wrist/Hand pain PastPresent
Upper back pain PastPresent
Lower back pain PastPresent
Hip pain PastPresent
Sciatica PastPresent
Scoliosis PastPresent
Leg pain PastPresent
Knee pain PastPresent
Ankle/Foot pain PastPresent
TMJ/Jaw pain PastPresent
Headache PastPresent
Migrane PastPresent
Arthritis PastPresent
Chronic fatigue PastPresent
Nervousness PastPresent
Depression PastPresent
Twitches/Tremors PastPresent
Rapid/Skipping heartbeat PastPresent
Insomnia PastPresent
Poor digestion PastPresent
Heartburn/acid reflux PastPresent
Gas/Bloating PastPresent
Constipation PastPresent
Diarrhea PastPresent
Hemorrhoids PastPresent
Diabetes PastPresent
Cancer PastPresent
Heart disease PastPresent
Irritable bowel/Colitis PastPresent
Crohn’s/Celiac PastPresent

Nausea PastPresent
Stomach pain PastPresent
Poor appetite PastPresent
Excessive hunger PastPresent
Vomiting PastPresent
Allergies/Hayfever PastPresent
Cold sores PastPresent
Sinus problems PastPresent
Asthma PastPresent
Earache/Ear infectionsPastPresent
Colds/Flu/Bronchitis PastPresent
High blood pressure PastPresent
Low blood pressure PastPresent
Cold hands & feet PastPresent
Bed-wetting PastPresent
Frequent urination PastPresent
Prostate trouble PastPresent
Ringing in ears PastPresent
Skin problems PastPresent
Varicose veins PastPresent
Eye problems PastPresent
Throat problems PastPresent
Thyroid problems PastPresent
Menstrual problems PastPresent
Fibrocystic diseasePastPresent
Weight problem PastPresent
Venereal disease PastPresent
Alcoholism PastPresent
Drug Abuse PastPresent

Please indicate any conditions, past or present, of any FAMILY MEMBERS:

Health IssueRelation to you
Allergies
Anxiety
Asthma
Back trouble
Bowel trouble
Cancer
Depression
Diabetes
Epilepsy

Health IssueRelation to you
Headaches
Heart disease
High blood pressure
Hormonal imbalance
Indigestion
Insomnia
Scoliosis
Sinusitis
Skin Issues
Other

Please describe the quality of your: 1 = Terrible, 10 = Terrific
Sleep 12345678910
Energy12345678910
Typical mood12345678910
Digestion12345678910
Job12345678910
Physical home environment12345678910
Physical work environment12345678910
Parental relationships12345678910
Friend relationships12345678910
Romantic relationships12345678910
Exercise12345678910
Food12345678910
Water12345678910
Rest and Relaxation12345678910
Spiritual life12345678910

Do you take: Birth control pillAspirin/Ibuprofen/etc.Antacid

Do you take:Vitamins/MineralsHerbsHomeopathicsProbiotics

Please indicate all of the following habits:

Alcohol NoneModerateHeavy
Coffee/Black tea NoneModerateHeavy
Tobacco NoneModerateHeavy
Marijuana NoneModerateHeavy
Sugar NoneModerateHeavy
Salt NoneModerateHeavy
Coke/Pepsi/etc. NoneModerateHeavy
Margarine/Crisco/etc. NoneModerateHeavy
Cold cuts NoneModerateHeavy
Fried Foods NoneModerateHeavy
Barbecue NoneModerateHeavy
Artificial Sweeteners NoneModerateHeavy
Artificial colorings & flavorings NoneModerateHeavy

Please describe your typical meals:

Who do you know (friends or family members) that have health issues that you are concerned about?

NameContact Information
(We appreciate your referrals. Refer a friend & receive a discount of 20% off your next visit with Dr. Martin.)

Dr. Martin’s Mission Statement

Our bodies heal themselves but, at times, need assistance in removing the interferences to their health potential. Our purpose is to enhance wellness and vitality by:
  1. Removing interference to your body’s neurological control through spinal adjustments,
  2. Removing interference to normal blood flow and good structural balance through bodywork (massage techniques), physical therapies and acupressure
  3. Removing toxins and malevolent organisms (such as candida-yeast) through cleansing and balancing the digestion and nutrition,
  4. Removing the charge on emotional issues and stresses through NeuroEmotional Technique and teaching stress management techniques.
We are here to serve the Philadelphia Area and beyond. Our Mission is to relieve suffering and restore health and to help our community become less dependent on medications and more reliant upon our body’s innate ability to heal through regular chiropractic care, good nutrition, exercise and a positive mental attitude. We specialize in difficult health challenges in infants, children and adults. We utilize a variety of healing modalities to suit the patient and to be thorough. We offer hope, sincerity, love and optimism to our patients. Please don’t hesitate to ask us about your health issues and how we might help you. Let’s make this your best year yet!

Dr. Martin’s PHILOSOPHY

I believe that the body knows how to heal itself of nearly everything, but at times becomes stuck or overwhelmed. It can be stuck or overwhelmed physically, chemically or emotionally. A condition may have come on suddenly, or taken months or years to develop. I believe many different healing techniques work and I choose to incorporate several of the best ones. I use a variety of the best techniques from chiropractic, kiniesiology, ayurveda, massage, and acupressure. I also believe that diet and nutrition play a critical role in our overall health. Therefore I incorporate, when needed, recommendations for changes in diet, nutritional supplements and cleansing programs. I also believe that emotions can interfere with healing and actually create certain conditions. Therefore, I utilize a quick and painless emotional clearing technique called NeuroEmotional Technique when called for. As an expert and an authority in facilitating the healing process, I will do my absolute best, using all that I know, to bring about healing for you as fast as possible, but I need your full cooperation and commitment in order for us to have success. This may mean agreeing to a treatment plan, changing your diet, taking certain supplements or adding a home exercise for example. I look forward to restoring you to your optimal health, and together we can make a difference! Thank you for putting your trust in me. Live Well & Thrive!