Phone:  770-368-0333
3949 Holcomb Bridge Rd, Suite 201
Norcross, GA 30092
Rick Neal, DC
Peachtree Corners Chiropractic Clinic
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ornamental grass in Dr. Neal's officeNew Patient Health Analysis
We provide our New Patient form in two formats for your convenience. Choose the one you prefer:
  • Download (here), to print and fill out by hand, or
  • Use your computer to fill out and print the form below.

To protect your confidentiality online, we do not support e-mailing this information. After you complete the form, use your browser to print it, and mail or bring it with you to our office. Thank you!
New Patient Information
Number: [ office use ] Date:    
Patient: Home Phone:    
Age: Marital Status:    
Occupation: Insurance Carrier:    
Address: City:    
State: Zip:    

Health Analysis
1. Do you need glasses to read? Yes   No
2. Do you need glasses to see things at a distance? Yes   No
3. Has you eyesight often blacked out completely? Yes   No
4. Do you eyes continually blink or water? Yes   No
5. Do you often have bad pains in your eyes? Yes   No
6. Are your eyes often red or inflamed? Yes   No
7. Are you hard of hearing? Yes   No
8. Have you ever had a fluid leaking from your ear? Yes   No
9. Do you have constant noises in your ears? Yes   No
10. Do you have to clear your throat constantly? Yes   No
11. Do you often feel a choking lump in your throat? Yes   No
12. Are you often troubled with bad spells of sneezing? Yes   No
13. Is your nose constantly stuffed up? Yes   No
14. Do you suffer from a constantly running nose? Yes   No
15. Have you at time had bad nose bleeds? Yes   No
16. Do you often catch severe colds? Yes   No
17. Do you frequently suffer from heavy chest colds? Yes   No
18. When you catch a cold, do you always have to go to bed? Yes   No
19. Do frequent colds keep you miserable all winter? Yes   No
20. Do you get hay fever? Yes   No
21. Do you suffer from asthma? Yes   No
22. Are you troubled by constant coughing? Yes   No
23. Have you ever coughed up blood? Yes   No
24. Do you wake up drenched with sweat in the middle of the night? Yes   No
25. Have you ever had a chronic chest condition? Yes   No
26. Have you ever had TB (tuberculosis)? Yes   No
27. Did you ever live with anyone who had TB? Yes   No
28. Has a doctor ever said your blood pressure was too high? Yes   No
29. Has a doctor ever said your blood pressure was too low? Yes   No
30. Do you have pains in the heart or chest? Yes   No
31. Are you often bothered by thumping of the heart? Yes   No
32. Does your heart often race like mad? Yes   No
33. Do you often have difficulty breathing? Yes   No
34. Do you get out of breath before anyone else? Yes   No
35. Do you sometimes get out of breath just sitting still? Yes   No
36. Are your ankles often badly swollen? Yes   No
37. Do cold hands or feet trouble you, even in hot weather? Yes   No
38. Do you suffer from frequent cramps in your legs? Yes   No
39. Has a doctor ever said you had heart trouble? Yes   No
40. Does heart trouble run in your family? Yes   No
41. Are your joints often painfully swollen? Yes   No
42. Do your muscles and joints constantly feel stiff? Yes   No
43. Do you usually have severe pains in the arms or legs? Yes   No
44. Are you crippled with severe arthritis? Yes   No
45. Does arthritis run in your family? Yes   No
46. Do weak or painful feet make your life miserable? Yes   No
47. Do pains in the back make it hard for you to keep up with your work? Yes   No
48. Are you troubled with a serious bodily disability or deformity? Yes   No
49. Do you suffer from frequent severe headaches? Yes   No
50. Does pressure or pain in the head often make life miserable? Yes   No
51. Are headaches common in your family? Yes   No
52. Do you have hot or cold spells? Yes   No
53. Do you often have spells of severe dizziness? Yes   No
54. Do you frequently feel faint? Yes   No
55. Have you fainted more that twice in your life? Yes   No
56. Do you have constant numbness or tingling in any part of your body? Yes   No
57. Was any part of your body ever paralyzed? Yes   No
58. Were you ever knocked unconscious? Yes   No
59. Have you ever had a twitching of the head face or shoulders? Yes   No
60. Did you ever have a seizure or convulsion (epilepsy)? Yes   No
61. Has anyone in your family ever had seizures or convulsion (epilepsy)? Yes   No
62. Do you bite your nails? Yes   No
63. Are you troubled by stuttering or stammering? Yes   No
64. Are you a sleep walker? Yes   No
65. Are you a bed wetter? Yes   No
66. Were you a bed wetter between the ages of 8 to 14? Yes   No
67. Do you have to get up every night and urinate? Yes   No
68. During the day, do you have to urinate frequently? Yes   No
69. Do you often have severe burning when you urinate? Yes   No
70. Do you sometimes lose control of your bladder? Yes   No
71. Has a doctor ever said you had kidney or bladder disease? Yes   No
72. Are you often exhausted or fatigued? Yes   No
73. Does working tire you out completely? Yes   No
74. Do you usually get up tired or exhausted in the morning? Yes   No
75. Does every little effort wear you out? Yes   No
76. Are you constantly too tired and exhausted to even eat? Yes   No
77. Do you suffer from severe nervous exhaustion? Yes   No
78. Does nervous exhaustion run in your family? Yes   No
79. Are you frequently ill? Yes   No
80. Are you frequently confined to bed by illness? Yes   No
81. Are you always in poor health? Yes   No
82. Are you considered a sickly person? Yes   No
83. Do you come from a sickly family? Yes   No
84. Do severe pains and aches make it impossible for you to do your work? Yes   No
85. Do you wear yourself out worrying about work? Yes   No
86. Are you always ill and unhappy? Yes   No
87. Are you constantly made miserable by poor health? Yes   No
 
   
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Dr. Neal is a member in good standing of the American Chiropractic Association (ACA), Acupuncture Society of American (ASA), Council on Extremity Adjusting (CEA) and the Georgia Chiropractic Association (GCA). American Chiropractic Association (ACA) Acupuncture Society of America (ASA) Council on Extremity Adjusting (CEA) Georgia Chiropractic Association (GCA)