#Atlanta

Natural Health Clinic

NEW PATIENT INFORMATION FORM
Page 1 of 2

Please print clearly:

Name _______________________________________________ Date ______________
Address _____________________________________________ Apt.# _____________
City ______________________________ State____________ ZIP_______________
Shipping Address _________________________________________________________
________________________________________________________________________
Home Phone (____) ____-_________ Work Phone (____) ____-_________
Social Security number: ________________________________
e-mail address: _______________________________________
REFERRED BY:_________________________________________________________
Occupation ________________________ Employer____________________________
Date of Birth _________________ Age ____ Sex: M/F Height _____ Weight _____
Overall health (circle one): Excellent / Good / Fair / Poor / Other: ___________________
Chief complaint (reason you are here): (use separate sheet if more room needed)
________________________________________________________________________
Previous treatments for this complaint _________________________________________
________________________________________________________________________
Other complaints or problems: (use separate sheet if needed) _______________________
________________________________________________________________________
Current medications/drugs being taken: (use separate sheet if needed) ________________
________________________________________________________________________
Are you currently under the care of a physician or other health care professionals?
(If yes, please give name and date of last visit):
________________________________________________________________________
Nutritional supplements you are taking: ________________________________________
Do you smoke, drink coffee or alcohol? (if yes indicate how much)
Cigarettes ______________ Coffee _________________ Alcohol________________
===============================================================
Office Use Only:
 Atlanta Natural Health Clinic
NEW PATIENT INFORMATION FORM
Page 2 of 2

Name: ______________________________________________ Date ______________

HISTORY:
List any major illnesses (with approx. dates): ___________________________________
________________________________________________________________________
List any surgery or operations with approx. date:_________________________________
________________________________________________________________________
Past Accidents or injuries: __________________________________________________
________________________________________________________________________
================================================================
Marital Status: S M D W Name of Spouse ____________________________
Describe health of spouse: _______________________ Number of children if any ____
Name of Child Age Sex Any physical conditions or concerns?
_________________________ ____ M/F _________________________________
_________________________ ____ M/F _________________________________
_________________________ ____ M/F _________________________________
Any family history of serious illnesses (circle those which apply): Cancer / Diabetes /
Heart / Other _____________________________________________________________
Any household pets or other animals you or family members are in close contact with:
________________________________________________________________________
What can we do to make you happier? _________________________________________
________________________________________________________________________

SIGNED:____________________________________________ DATE ____________

 SYMPTOM SURVEY FORM

NAME ______________________________ DOCTOR ____________________________ DATE____________

INSTRUCTIONS: Number the boxes which apply to you with either a 1, 2, or 3
AGE______ SEX M____ F ____ (1) for MILD symptoms
(2) for MODERATE symptoms
Phone # (_____) ___________________ (3) for SEVERE symptoms
Leave the box BLANK if it does not apply to you!

GROUP 1 GROUP 2
1 □ Acid foods upset 21 □ Joint stiffness after arising
GROUP 3
2 □ Get chilled, often 22 □ Muscle-leg-toe cramps at night
3 □ "Lump" in throat 23 □ "Butterfly" stomach, cramps 42 □ Eat when nervous
4 □ Dry mouth-eyes-nose 24 □ Eyes or nose watery 43 □ Excessive appetite
5 □ Pulse speeds after meals 25 □ Eyes blink often 44 □ Hungry between meals
6 □ Keyed up - fail to calm 26 □ Eyelids swollen, puffy 45 □ Irritable before meals
7 □ Cuts heal slowly 27 □ Indigestion soon after meals 46 □ Get "shaky" if hungry
8 □ Gag easily 28 □ Always seems hungry; feel 47 □ Fatigue, eating relieves
9 □ Unable to relax; startles easily "lightheaded" often 48 □ "Lightheaded" if meals delayed
10 □ Extremities cold, clammy 29 □ Digestion rapid 49 □ Heart palpitates if meals missed
11 □ Strong light irritates 30 □ Vomiting frequent or delayed
12 □ Urine amount reduced 31 □ Hoarseness frequent 50 □ Afternoon headaches
13 □ Heart pounds after retiring 32 □ Breathing irregular 51 □ Overeating sweets upsets
14 □ "Nervous" stomach 33 □ Pulse slow; feels "irregular" 52 □ Awaken after few hours sleeps -
15 □ Appetite reduced 34 □ Gagging reflex slow hard to get back to sleep
16 □ Cold sweats often 35 □ Difficulty swallowing 53 □ Crave candy or coffee in
17 □ Fever easily raised 36 □ Constipation, diarrhea alternating afternoons
18 □ Neuralgia-like pains 37 □ "Slow starter" 54 □ Moods of depression - "blues" or
19 □ Staring, blinks little 38 □ Get "chilled" infrequently melancholy
20 □ Sour stomach frequent 39 □ Perspire easily 55 □ Abnormal craving for sweets or
40 □ Circulation poor, sensitive to cold snacks
GROUP 4 41 □ Subject to colds, asthma,
bronchitis
56 □ Hands and feet go to sleep easily,
numbness
57 □ Sigh frequently, "air hunger"
GROUP 5
58 □ Aware of "breathing heavily"
59 □ High altitude discomfort
60 □ Opens windows in closed room 73 □ Dizziness 86 □ Skin peels on foot soles
61 □ Susceptive to colds and fevers 74 □ Dry Skin 87 □ Pain between shoulder blades
62 □ Afternoon "yawner" 75 □ Burning feet 88 □ Use laxatives
63 □ Get "drowsy" often 76 □ Blurred vision 89 □ Stools alternate from soft to
64 □ Swollen ankles worse at night 77 □ Itching skin and feet watery
65 □ Muscle cramps, worse during 78 □ Excessive falling hair 90 □ History of gallbladder attacks or
exercise; get "charley horses" 79 □ Frequent skin rashes gallstones
66 □ Shortness of breath on exertion 80 □ Bitter, metallic taste in mouth in 91 □ Sneezing attaches
67 □ Dull pain in chest or radiating into mornings 92 □ Dreaming, nightmare type bad
left arm, worse on exertion 81 □ Bowel movement painful or dreams
68 □ Bruise easily, "black/blue" spots difficult 93 □ Bad breath (halitosis)
69 □ Tendency to anemia 82 □ Worries, feels insecure 94 □ Milk products cause distress
70 □ "Nose bleeds" frequent 83 □ Felling queasy; headache over 95 □ Sensitive to hot weather
71 □ Noises in head or "ringing in ears" eyes 96 □ Burning or itching anus
72 □ Tension under the breastbone, or 84 □ Greasy foods upset 97 □ Crave sweets
feeling of "tightness", worse on 85 □ Stools light-colored
exertion

Copyright © 2005. Dr. Freddie Ulan. All Rights Reserved. Printed in U.S.A.
 GROUP 6 GROUP 7 (continued) FEMALE ONLY
98 □ Loss of taste for meat 173 □ Very easily fatigued
99 □ Lower bowel gas several hours (C) 174 □ Premenstrual tension
after eating 137 □ Failing memory 175 □ Painful menses
100 □ Burning stomach sensations, 138 □ Low blood pressure 176 □ Depressed feeling before
eating relieves 139 □ Increased sex drive menstruation
101 □ Coated tongue 140 □ Headaches, "splitting or rending" 177 □ Menstruation excessive and
102 □ Pass large amounts of foul- type prolonged
smelling gas 141 □ Decreased sugar tolerance 178 □ Painful breasts
103 □ Indigestion 1/2 - 1 hour after 179 □ Menstruate too frequently
eating; may be up to 3-4 hrs. (D) 180 □ Vaginal discharge
104 □ Mucus colitis or "irritable bowel" 142 □ Abnormal thirst 181 □ Hysterectomy/ovaries removed
105 □ Gas shortly after eating 143 □ Bloating of abdomen 182 □ Menopausal hot flashes
106 □ Stomach "bloating" after eating 144 □ Weight gain around hips or waist 183 □ Menses scanty or missed
145 □ Sex drive reduced or lacking 184 □ Acne, worse at menses
146 □ Tendency to ulcers, colitis 185 □ Depression of long standing
GROUP 7 147 □ Increased sugar tolerance
(A) 148 □ Women: menstrual disorders
MALES ONLY
107 □ Insomnia 149 □ Young girls: lack of menstrual
108 □ Nervousness function 186 □ Prostate trouble
109 □ Can't gain weight 187 □ Urination difficult or dribbling
110 □ Intolerance to heat
(E) 188 □ Night urination frequent
111 □ Highly emotional
150 □ Dizziness 189 □ Depression
112 □ Flush easily
151 □ Headaches 190 □ Pain on inside of legs or heels
113 □ Night sweats
152 □ Hot flashes 191 □ Feeling of incomplete bowel
114 □ Thin, moist skin
153 □ Increased blood pressure evacuation
115 □ Inward trembling
154 □ Hair growth on face or body 192 □ Lack of energy
116 □ Heart palpitates
(female) 193 □ Migrating aches and pains
117 □ Increased appetite without
155 □ Sugar in urine (not diabetes) 194 □ Tire too easily
weight gain
156 □ Masculine tendencies (female) 195 □ Avoid activity
118 □ Pulse fast at rest 196 □ Leg nervousness at night
119 □ Eyelids and face twitch
(F) 197 □ Diminished sex drive
157 □ Weakness, dizziness
120 □ Irritable and restless
158 □ Chronic fatigue
121 □ Can't work under pressure
159 □ Low blood pressure IMPORTANT
160 □ Nails weak, ridged
(B)
161 □ Tendency to hives TO THE PATIENT: Please list below
122 □ Increase in weight
162 □ Arthritic tendencies the five main health complaints you
123 □ Decrease in appetite
163 □ Perspiration increase have in order of their importance:
124 □ Fatigue easily
164 □ Bowel disorders 1. ___________________________
125 □ Ringing in ears
165 □ Poor circulation
126 □ Sleepy during day
166 □ Swollen ankles
___________________________
127 □ Sensitive to cold
167 □ Crave salt 2. ___________________________
128 □ Dry or scaly skin
□
168 Brown spots or bronzing of skin ___________________________
129 □ Constipation
169 □ Allergies - tendency to asthma
130 □ Metal sluggishness
170 □ Weakness after colds, influenza
3. ___________________________
131 □ Hair coarse, falls out
171 □ Exhaustion - muscular and ___________________________
132 □ Headaches upon arising wear off
nervous
during day 4. ___________________________
133 □ Slow pulse, below 65
172 □ Respiratory disorders
___________________________
134 □ Frequency of urination 5. ___________________________
135 □ Impaired hearing
136 □ Reduced initiative ___________________________

Copyright © 2005. Dr. Freddie Ulan. All Rights Reserved. Printed in U.S.A.
FINANCIAL AGREEMENT
the purpose of this agreement is to clarify your financial responsibilities so we can devote our efforts to helping you to get the best
results in the shortest amount of time. The following are the most common services we provide:
PROCEDURE PURPOSE WHEN PERFORMED FEE

CONSULTATION Meet with the doctor, discuss your reasons for being First visit, new injuries, or No charge
here, review your case history new condition
EVALUATION / Ascertain the nature and severity of your health First visits, new conditions, $60. -.$150
EXAM problem. Assess and evaluate your new or current exacerbation's, and
health status and determine and appropriate course of progress examinations
action
DIAGNOSTIC Visualize the location of spinal problems and confirm As necessary for 1st visit, $25. -.$150.
IMAGING (X-RAYS, other exam findings. re-injuries and progress
SEMG AND examinations
THERMAL SCANS)
CHIROPRACTIC Reduce and remove the Vertebral Subluxation Complex As indicated by $35. - $55.
ADJUSTMENTS examination and evaluation
MASSAGE THERAPY Stress reduction, speed healing process, provide As indicated by 1/2 hour = $40.
muscular relief and increase circulation examination and evaluation 1 hour = $65.
and interest of patient 1 1/2 hour =$90.
NUTRITIONAL Access any nutritional imbalances or toxins that may be As indicated by $120. Initial Eval.
RESPONSE contributing to or compromising your body’s ability to examination and evaluation $30. Re-eval.
TESTING heal and function at it’s optimal state and interest of patient

Forms of Payment
We accept cash, personal checks, Visa, Mastercard, Discover, Tradebank, and Barter For Less. Payment is expected at time of
service unless other arrangements have been made. Services may be paid for in advance.
Insurance / Third Party Pay
As a service to you, we will be happy to file your insurance claims and accept payment from your insurance company. After
verifying coverage, we will explain what portion of your bill is expected to be paid by your insurance company. It is important to
understand that you are still responsible to pay for services provided to you. If you would like our staff to check your
chiropractic benefits, please present your insurance card when you return these forms and please sign after the following
statements.

I authorize the release of health or other information necessary to process any claims. I also authorize payment of
chiropractic benefits to be paid to the Atlanta Natural Health Clinic . _____________________________________________

Special Arrangements
We have never denied anyone the benefit of chiropractic care due to their inability to pay our published fees. Individual contracts
can be designed to help specific financial needs. The most important thing to us is that people are given what they need.
Billing
Billing is taken care of at the front desk unless other arrangements need to be made.

Preferred Chiropractic Doctor (PCD)

Dr. Hurd is a participating provider with a national organization that legally allows us to reduce our fees for participating
members. PCD membership is available to all patients. Reduced fees are only applicable when insurance reimbursement is not
going to be used. Annual fees are $30. per individual and $45. perfamily. You can join here or online at www.bewell2.com.

I have read and agree to this financial agreement.

Signature of patient: Date: