new patient form

Thank you for filling out our patient forms! Please keep in mind that we will need you to fill both the New Patient Form and the Patient Intake Form.

New Patient Info

Last Name*

First Name*

Middle

Gender

S.S#

Date of Birth

Age

Marital Status

Home Address

City

State

Zip

Home Phone

Cell

Email Address

Employers Name

Occupation

Employers Address

Suite #

City

State

Zip

Work Phone #

Spouse or Guardian

Name
SS#

Date of Birth

Work Phone#
Employment

Home address

Phone#

Emergency Contact

Name
Phone#
Relatation to Patient
Work Phone#
PRIMARY INS.
ID
Group#
SECONDARY INS.
ID
Group#
Policy Holder's Name
Date of Birth

Do You Need a referral?

Who may we thank for referring you?

Insurance Assignment and Release: I certify that I, and/or my dependent(s), have insurance coverage with

and assign directly to Dr. Brandon Cooper, D.C., all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance. If insurance payments have not been received, or are denied by my insurance company, I agree to pay for services rendered within thirty (30) days of the written request by Cooper Chiropractic and Wellness, LLC. I further agree that I will pay all additional fees if a collection agency, or similar institution, is utilized to collect my payment. I authorize the use of my signature on all insurance submissions. Dr. Brandon Cooper, D.C. may use my health care information and may disclose such information the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
​​​​​​​

Patient Intake Form

Patient Name

Date

Indicate below where you have pain/symptoms

How often do you experience your symptoms?

How would you describe the type of pain

If other please specify

How are your symptoms changing with time?

Using a scale from 0-10 (10 being the worst), how would you rate your problem?

How much has the problem interfered with your work?

How much has the problem interfered with your social activities?

Who else have you seen for your problem?

If other please specify

How long have you had this problem?

How do you think your problem began?

Do you consider this problem to be severe?

What aggravates your problem?

What concerns you the most about your problem; what does it prevent you from doing?

What is your?

Height
Weight
Date of Birth
Occupation

How would you rate your overall Health?

What type of exercise do you do?

Indicate if you have any immediate family members with any of the following:

For each of the conditions listed below, place a check in the "past" column if you have had the condition in the past. If you presently have a condition listed below, place a check in the "present" column.

Headaches
Neck Pain
Upper Back Pain
Mid Back Pain
Low Back Pain
Shoulder Pain
Elbow/Upper Arm Pain
Wrist Pain
Hand Pain
Hip Pain
Upper Leg Pain
Knee Pain
Ankle/Foot Pain
Jaw Pain
Joint Pain/Stiffness
Arthritis
Rheumatoid Arthritis
Cancer
Tumor
Asthma
Chronic Sinusitis
Chronic Sinusitis
High Blood Pressure
Heart Attack
Chest Pains
Stroke
Angina
Kidney Stones
Kidney Disorders
Bladder Infection
Painful Urination
Loss of Bladder Control
Prostate Problems
Abnormal Weight Gain/Loss
Loss of Appetite
Abdominal Pain
Ulcer
Hepatitis
Liver/Gall Bladder Disorder
General Fatigue
Muscular Incoordination
Visual Disturbances
Dizziness
Diabetes
Excessive Thirst
Frequent Urination
Smoking/Tobacco Use
Drug/Alcohol Dependance
Allergies
Depression
Systemic Lupus
Epilepsy
Dermatitis/Eczema/Rash
HIV/AIDS

​​​​​​​For Females Only
Birth Control Pills
Hormonal Replacement
Pregnancy
Other condition

List all prescription medications you are currently taking:

List all of the over-the-counter medications you are currently taking:

List all surgical procedures you have had:

What activities do you do at work?

Sit

Stand

Computer work

On the phone

What activities do you do outside of work ?

Have you ever been hospitalized?

if yes, why?

Have you had significant past trauma?

Anything else pertinent to your visit today?

Patient Signature

Date

Upload images of your insurance card here:
Front of card:
Back of card:
none Home Visits Only
By Appointment 7:30 AM - 5:45 PM 7:30 AM - 5:30 PM 7:30 AM - 12:30 PM
House Calls From
2:00 PM - 6:00 PM 7:30 AM - 4:00 PM 8:00 AM - 3:00 PM
Every Other Sat Closed chiropractor https://www.google.com/search?ei=ideRX5OSAseOtQXP46-YAg&q=Cooper+Chiropractic+%26+Wellness+Center+New+York&oq=Cooper+Chiropractic+%26+Wellness+Center+New+York&gs_lcp=CgZwc3ktYWIQAzIFCCEQoAEyBQghEKABMgUIIRCrAjoECAAQRzoJCAAQyQMQFhAeOgYIABAWEB46CAghEBYQHRAeOgQIIRAKUKEsWNZHYI9JaANwAngAgAHwAogBvQ6SAQgwLjExLjAuMZgBAKABAaoBB2d3cy13aXrIAQjAAQE&sclient=psy-ab&ved=0ahUKEwjT-rr48cjsAhVHR60KHc_xCyMQ4dUDCA0&uact=5#lrd=0x89c259a66a6a5f89:0x919d30aa00f17d4,3,,, https://www.yelp.com/writeareview/biz/ES0mRbmlHefbHqP4oPZLAQ?return_url=%2Fbiz%2FES0mRbmlHefbHqP4oPZLAQ&source=biz_details_war_button https://www.facebook.com/Cooper-Chiropractic-and-Wellness-Center-101096116895941/reviews/?ref=page_internal https://www.zocdoc.com/doctor/brandon-cooper-dc-lac-diplac-215073?insuranceCarrier=-1&insurancePlan=-1