ZEN HEALTH CENTER - NEW PATIENT INTAKE FORM

First Name: _____________________ Middle Initial: _____ Last Name: ___________________________

Date of Birth: _____/_____/_____ Sex: Male Female Email: __________________________________
Address: _______________________________________________________________________________
City: ____________________________ State: _______________ Zip Code: ________________________
Home Phone: (_______) ________-____________ Cell Phone: (_______) ________-____________
Cell Phone Carrier: Verizon AT&T T-Mobile Sprint Other __________________
Social Security Number: _________-_______-____________(For Chiroplan, Medicare, and Triwest Patients)
Race (If Multi-Racial check all that apply):
White

African American

Hispanic

American Indian/Alaskan Native

Japanese

Korean

Chinese

Filipino

Native Hawaiian or other Pacific Islander

Vietnamese Other _______________ I choose not to specify

Ethnicity:

Hispanic or Latino Not Hispanic or Latino

I choose not to specify

Preferred Language:
English

Chinese

Other _______________

I choose not to specify

Spouse Data
Marital Status Single Married Other

Is your spouse a patient at this clinic? Yes No

First Name: ___________________ Middle Initial ___ Last Name: ______________________

Phone: (______) _______-____________

Emergency Contact
Contact Name: ___________________________ Phone: (______) _______-____________

Employer Data
Employment Status: Employed Full Time Student Part Time Student Other

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ZEN HEALTH CENTER - NEW PATIENT INTAKE FORM

Your Occupation: ________________________ Employers Name: ______________________________

Insurance Information
SKIP THIS SECTION UNLESS YOU ARE INSURED BY SOMEONE OTHER THAN YOURSELF
Relationship to Insured: Spouse Child

Insureds Date of Birth: _____/_____/_____

Insureds Social Security Number: _________-_______-_________________

Referral Information
How did you hear about our clinic?
Family/Friend ______________ Physician ____________ Online ___________ Other ____________

Primary Physician
Please list your primary physicians name here: _______________________________________________

Medical Conditions
Review of Body Symptoms:
Musculoskeletal:

Have

Had

None

If yes, which ____________________________

Neurological:

Have

Had

None

If yes, which ____________________________

Cardiovascular:

Have

Had

None

If yes, which ____________________________

Respiratory:

Have

Had

None

If yes, which ____________________________

Digestive:

Have

Had

None

If yes, which ____________________________

Sensory:

Have

Had

None

If yes, which ____________________________

Integumentary/Skin:

Have

Had

None

If yes, which ____________________________

Endocrine:

Have

Had

None

If yes, which ____________________________

Genitourinary:

Have

Had

None

If yes, which ____________________________

Constitutional:

Have

Had

None

If yes, which ____________________________

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ZEN HEALTH CENTER - NEW PATIENT INTAKE FORM

Surgeries: None
Appendectomy

Cardiovascular procedure Cervical Disc Procedure Hysterectomy

Joint Replacement

Laminectomies

Radical prostatectomy Prostate surgery

Hospitalizations/Injuries: Reason: ______________________________ Date: ____________________

Allergies: None
Eggs

Fish or shellfish

Milk or Lactose

Peanut

Soy

Sulfites

Wheat/Gluten

Medications _____________

Symptoms: _____________________________________
Smoking History:
Smoke Tobacco: Never Occasionally Often
If often, how much? 1 pack or less per day 1 pack or more daily
What is your interest in quitting smoking? No interest Some interest Very interested

Social History:
Drink alcohol: Never Occasionally Often
Coffee Used: Never Occasionally Often
Soda Pop Used: Never Occasionally Often
Recreational Drug Use: Never Occasionally Often If yes, please specify ________________________
Your health eating habits:
Excellent
Very Good

Good

Fair

Poor

Exercise: Never Occasionally Often

Experience Physical Stress: Never Occasionally Often
Experience Emotional Stress: Never Occasionally Often

Family History (If applies, please circle Sibling/Parent):

Cancer:______________(Sibling/Dad/Mom) Cholesterol (Sibling/Dad/Mom) Stroke (Sibling/Dad/Mom)
Heart Problems:_______________ (Sibling/Dad/Mom) Hypertension (Sibling/Dad/Mom)

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ZEN HEALTH CENTER - NEW PATIENT INTAKE FORM

Current Medications:
Are you currently taking medications or supplements? Yes

No

If yes, what are you taking and how often?

_____________________________________________________________________
When did you begin this medication?
___________________________________________________________
Obtained: Over the counter By prescription

Symptoms
What describes the nature of your symptoms?
Sharp

Dull ache

Numb

Have you had similar symptoms in the past?

Shooting

Burning

Yes

No

Tingling Stabbing

If you have seen treatment for the past for the same or similar symptoms, who did you see?
Other Chiropractor

Medical Doctor

Physical Therapist

Other ________________

By using the key below, indicate on the body diagram where you are experiencing the following symptoms:
# = Numbness

X = Burning

/ = Stabbing

0 = Pins & Needles

+ = Dull Ache

Describe your symptoms:

________________________________________________________________________________________
________________________________________________________________________________________

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ZEN HEALTH CENTER - NEW PATIENT INTAKE FORM

When did your symptoms begin?
________________________________________________________________________________________
How did your symptoms begin?
_______________________________________________________________________________________
How often do you experience your symptoms?
Constantly
(76-100% of the day)

Frequently
(51-75% of the day)

Occasionally
(26-50% of the day)

Intermittently
(0-25% of the day)

How are your symptoms changing?

Getting better

Getting worse

Not changing

Who have you seen for your current symptoms?

No one
Other

Other Chiropractor

Medical Doctor

Physical Therapist

What treatment did you receive for your symptoms?

Adjustments
Other

Physical Therapy

Medication

Surgery

3 6 months ago
5 10 years ago

6 months to 1 year ago

CT Scan

Other

3 6 months ago
5 10 years ago

6 months to 1 year ago

When did you receive this treatment?

In the last month
1 2 years ago

2 3 months ago
2 5 years ago

What tests have you had for your symptoms?

X-rays

MRI

When were these tests done?

In the last month
1 - 2 years ago

2 3 months ago
2 5 years ago

During the past 4 weeks, indicate the average intensity of your symptoms: (0 = None to 10 =
Unbearable)
0 None

1-2

7-8

9-10 Unbearable

3-4

5-6

During the past 4 weeks, how much has pain interfered with your normal work (including both work outside the
home and housework):
Not at all

A little bit

Moderately

Quite a bit

Extremely

During the past 4 weeks, how much of the time has your condition interfered with your social
activities?
All of the time

Most of the time

Some of the time

A little of the time

None of the time

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ZEN HEALTH CENTER - NEW PATIENT INTAKE FORM

ZEN HEALTH CENTER POLICIES

PAYMENT AND PATIENT DATA

1.
2.
3.
4.
5.

PAYMENT is due at the time of service, unless other arrangements have been made.
AN INSURANCE CONTRACT is between the patient and the patients insurance company; therefore it is the
responsibility of the patient to keep the account current.
The patient is responsible for keeping track of his/her medical visits, especially when visiting other clinics; in
relation to plan benefits.
Patients involved in LITIGATION (lawsuits) are, as are others, responsible for their service here at the clinic.
Personal cleanliness is requested due to the close interpersonal nature of this work.

ATTENDANCE
1.
2.

Patient must arrive on time; otherwise the appointment will be reduced or rescheduled.
It is the patients responsibility to notify the office, at least 24 hours in advance, if the appointment will be
cancelled or rescheduled.
3.
We reserve the right to BILL FOR MISSED APPOINTMENTS. There will be a $25 charge per appointment.
4.
Failure to comply with attendance policies can affect, and possibly terminate, your future treatments at the
center.

I have received a copy of the NOTICE OF PRIVACY PRACTICES (HIPAA)

My signature is an acknowledgement that I have read the policy above and agree to abide by the same and
authorize the office of Hong Zeng Yuen-Schat (Dr. Zen), D.C. to treat and/or release any medical information
necessary to process this claim and request payment of benefits to either to myself or to the party who
accepts assignment below.

_____________________________________________________
Signature of Patient

________________________
Date

(or Legal Guardian if Patient under 18)

If youve been injured in an auto or work accident please fill out Auto/Workers Comp Form.
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