New Patient Forms

Resonate Wellness

5611 NW 1st St, Suite 102
Lincoln, NE
hello@resonatewellnessne.com
Copyright 2025

Patient Data Sheet

First name

Last name

Today's Date

Date of Birth

Month

Day

Year

Age

Gender

Male

Female

Other

Marital status

Married

Single

Divorced

Widowed

Multi-line address

Country/Region

Address

City

Zip / Postal code

Email

Phone

Emergency Contact (Name)

Emergency contact relationship

Spouse

Parent

Child

Friend

Emergency Contact Phone

Purpose of appointment

Describe your typical exercise and/or recreational activities

(Example: "Walk 1 mile every day", "Cardio at the gym 3 days/week")

Have you ever had any major accidents or injuries in your life, including auto accidents?

Yes

No

Have you ever had any surgeries?

Yes

No

How would you describe your general state of health?

Excellent

Good

Fair

Poor

Please list any current medical diagnoses you have received and the treatment you are getting (if any)

Have you ever received Chiropractic care before?

Yes

No

Do you get regular medical check-ups for your general health?

Yes

No

Please list any medications you take, including over-the-counter products, like Advil:

Please list any vitamins/supplements you take:

By signing below, you acknowledge that all statements/information you have made on this form are accurate, complete, and true to the best of your knowledge:

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Please fill out and submit the new patient forms below. If you haven't scheduled your session yet, you can use the scheduling page once you've submitted the forms.

For any questions, please reach out to me directly.

Find our HIPAA notice here.