4 Northeast 4th Avenue, Pompano Beach FL 33060

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Welcome to Pompano Beach Chiropractic Clinic! As a new patient, you can save time and streamline your visit by completing our easy online form before you arrive. This will help us get to know you better and ensure we provide the best care possible.

Thank you, and we look forward to meeting you!

Your Information

Have You Visited Lighthouse Medical Center Before?

I'm a New Patient

Yes, I Have

First Name *

Last Name *

Address

Street Address

City

State

Country

Country

Postal code

Email *

Phone *

Date of birth

Example 05/30/1972

Occupation

Employer

Marital Status

Marital Status

Single
Married
Other
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How Did You Hear About Us?

How Did You Hear About Us?

Radio or TV Ad
Facebook
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A Friend Referred You
Google Search
Direct Mail (Letter or Postcard)
Other
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Emergency Contact

Emergency Conatct Full Name

Relationship

Phone Number

Your Insurance

Primary Insurance Company

Primary Insurance Company

United Healthcare
BlueCross BlueShield
Cigna
Aetna
Other
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Subscriber Name

Plan

Reason For Appt:

Nerve Pain

Knee Pain

Foot Pain

Shoulder Pain

Nutritional Therapy

Allergies

Corrective Therapy

Peptides Therapy

Weight Loss

IV Therapy

Spine Pain

Auto Injury

If Injured, What Body Part?

If Injured, What Body Part?

Neck
Back
Limbs
Wrist
Ankle
Shoulder
Scoliosis
Hip
Knee
SI Joint
Plantar Fasciitis
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Side of Body

Left

Right

Bilateral

Injury Date

Please Briefly Describe Injury

Were You Seen In the Emergency Room

Yes, I was

No, I was not

If yes, where were you seen?

Past Medical History

Have you ever had:

Select all that apply

HYPERTENSION
LIVER DISEASE
HYPERLIPIDEMIA
STROKE
MIGRAINES
HEARTBURN
ANEMIA
KIDNEY STONES
SKIN CANCER
PROSTATE CANCER
GASTRITIS
OSTEOARTHRITIS
CORONARY ARTERY DISEASE
DIABETES MELLITUS
SEIZURE
HYPOTHYROIDISM
EDEMA
ASTHMA
CANCER
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Are You Currently On Any Medications?

Yes, I am

No, I am not

If you answered yes, please lest all medications (Name, Dosage, Frequency) OR Upload Image of Labels Below

Prescription Label Upload

Take a Picture of Medication Label

Do You Have Allergies?

Yes, I do

No, I do not

If yes, please include all allergens (Medications, Foods, Seasonal)

Surgical History:

Please select all that apply

TONSILS
OVARY
HERNIA REPAIR
APPENDIX
UTERUS
GALL BLADDER
ORTHOPEDICS
OTHER
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Family History:

Select all that apply

CARDIAC
STROKE 2
CANCER
OSTEOARTHRITIS
DIABETES
OTHER
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Do you have either/both of the following:

Pacemaker

Defibrillator

Do you smoke?

Yes, I do

No, I do not

If you smoke, how many cigarettes per day and how many years have you been smoking?

Do you consume alcohol?

Yes, I do

No, I do not

If you drink, how many drinks per day/week?

Body Systems Review

Constitutional Symptoms

Select all that apply

Recent weight change (gain or loss)
Fatigue or general weakness
Fever
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Eyes/Vision

Select all that apply

Eye disease or injury
Wear glasses or contact lenses
Blurred or double vision
Glaucoma
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Ears Nose Mouth & Throat

Select all that apply

Hearing loss or ringing in ears
Nose bleeds
Sore throat, hoarseness, or voice change
Swollen glands in neck
Chronic sinus problems or rhinitis
Bleeding gums
Difficulty swallowing
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Cardiovascular System

Select all that apply

Heart trouble
Palpitations (irregular or forceful heart beats)
Shortness of breath with walking or lying flat
Swelling of feet, ankles, or hands
Angina pectoris (chest pain, discomfort, or tightness)
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Gastrointestinal System

Select all that apply

Loss of appetite
Nauseas or vomiting
Painful bowel movements or constipation 3
Abdominal pain
Change in bowel movements
Frequent diarrhea
Rectal bleeding or blood instool
Peptic ulcer (stomach or duodenal)
Frequent heart burn
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Psychiatric Health

Select all that apply

Memory loss or confusion
Difficulty concentrating
Depression
Insomnia
Nervousness or anxiety
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Neurological System

Select all that apply

Frequent or recurring headaches
Head injury
Stroke
Numbness or tingling sensations
Light-headed or dizzy
Poor balance
Paralysis
Tremors or shaking
Convulsions or seizures
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Genitourinary System

Genitourinary System

Frequent urination
Incontinence of dribbling
Male - testicle pain or swelling
Female - pain with periods
Burning or painful urination
Kidney stones
Sexual difficulties
Female - irregular periods
Female - vaginal discharge
Denital infections or STD
Change inforce of strain when urinating
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Intergumentary System & Breast Health

Intergumentary System & Breast Health

Skin rash or itching
Changes in nail growth or condition
Breast pain
Breast lump
Hair loss or other scalp problems
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Endocrine System

Endocrine System

Thyroid disease
Diabetes
Excessive thirst or urination
Heat or cold intolerance
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Hematologic & Lymphatic System

Hematologic & Lymphatic System

Bleeding or bruising tendency
Anemia (low red blood cell levels)
Varicose (enlarged or twisted) veins in legs
Past blood transfusions
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Pompano Beach Chiropractic Clinic The Experts in Chiropractic and Holistic Care in Pompano Beach, FL.

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(954) 943-1044Click To Call Us Now

Office Hours

Monday 8 am-12 pm & 2 pm-6 pm

Tuesday 8 am-12 pm & 2 pm-6 pm

Wednesday 9 am -12 pm

Thursday 2 pm-6 pm

Friday 9 am -12 pm

4 NE 4th Ave, Pompano Beach, FL 33060, USA

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