Laboratory for Wellness & Motor Behavior (LWMB)

- New Patient Application -

Welcome to our Practice! Please thoroughly complete all questions. Thank you.
Name:

Todays Date:

Address:
City/State/Zip:
Phone (H)
Marital status: M/W/D/S

E-Mail:
(W)

Cell

Birth Date:

Age:

Social Security #:

Whom may we thank for referring you?

Assigned Physician:

Occupation:

City, State:

Last Visit

Employers name:

Employers address:
Spouses name:

Spouses employer:

Childrens names & ages:

,
,

Favorite hobbies or interests:

Health reasons for consulting our office:
1.
2.
3.
4.
Have you had same or similar problem(s) before?

Yes or No

Please explain:
Family with similar problems?
Is this the result of an auto or work injury?
Other doctors who have treated this problem:

If so, when?

If so, how long?

Surgeries you have had:

Medication(s) you are currently taking:

Is there any chance you are pregnant?

Yes or No

If the doctor recommends care, does this office have your permission to correspond with your
primary physician with the goal of keeping them informed regarding our findings? Yes or No
If the doctor recommends care, will you be using health insurance?
Insurance Company Name(s)
Method of payment for first visit:

Yes or No
ID#

Cash

Check

Credit Card (VISA, MC, Amex)

The above information is true and accurate to the best of my knowledge. My reason for
consultation with the Doctor is for evaluation of my physical health and the potential for
improvement.
Patient or Guardian Signature:

Todays Date: