OPTIMUM HEALTH THROUGH CHIROPRACTIC CARE

 

Patient Information

Thank you for choosing our practice for your chiropractic needs.  Please complete this form in ink.  If you have any questions or concerns, do not hesitate to ask for assistance.  We will be happy to help.

 

(Please Print)

Name ______________________________ Date ___________ SS# _________________

             First     Middle Initial     Last

Address ______________________________ City____________ State_____ Zip _________

Sex: □ Female  □ Male    

Birthdate ________________ Email ______________________________________

Home Phone(___)___________ Cell Phone (___)___________ Work Phone (___)__________

Do you prefer to receive calls at:      □ Home        □ Work          □ Cell     □ No Preference

□ Married  □ Widowed  □ Single  □ Minor  □ Separated  □ Divorced  □Partnered for __ years

Patient Employer/School ________________________ Occupation _____________________  Employer/School Address ________________________ City ________ State ___ Zip_______

Spouse or Parent’s Name _____________ Employer ___________ Work Phone(___)_________

Whom may we thank for referring you to us? _________________________________________

Person to contact in case of emergency ____________________ Phone (__)________________

 

Responsible Party

Name of person responsible for this account ________________________________________

Relationship to patient ____________________ Phone  (_____)_______________________

Address _________________________________ City _____________ State ___ Zip _______

Name of employer __________________________ Work Phone (___)__________________

 

Symptoms

Reason for visit ______________________ When did you first notice the symptoms?_______

Is this condition getting progressively worse? _______________________________________

Where specifically is the problem(s) located? ________________________________________

Which activities are difficult to perform?  □ Sitting □ Standing  □ Walking  □ Bending 

□ Laying Down   □ Other _______________________________

Type of pain:   □ Sharp    □ Dull    □ Throbbing   □ Numbness  □ Aching   □ Shooting

 □ Burning    □ Tingling    □ Cramps   □ Stiffness    □ Swelling     □ Other _________________

Rate the severity of your pain.  (1, mild pain or discomfort, to 10, severe pain):

   1  2  3  4  5  6  7  8  9  10

Is the pain constant or does it come and go? ______________________________________

What treatment have you already received for your condition?

□Medication      □Surgery          □Physical Therapy         □Other_______________

Name and address of other doctor(s) who have treated you for your condition:

_____________________________________________________________________________

 

 -Confidential-

 

 Health History

Check only those conditions which are applicable:

 

□ AIDS/HIV

□ Alcoholism

□ Allergy Shots

□ Anemia

□ Anorexia

□ Appendicitis

□ Arthritis

□ Asthma

□ Bleeding Disorders

□ Breast Lump

□ Bronchitis

□ Bulimia

□ Cancer

□ Cataracts

□ Chemical Dependency

□ Chicken Pox

□ Depression

□ Diabetes

□ Emphysema

□ Epilepsy

□ Fractures

□ Glaucoma

□ Goiter

□ Gonorrhea

□ Gout

□ Heart Disease

□ Hepatitis

□ Hernia

□ Herniated Disc

□ Herpes

□ High Cholesterol

□ Kidney Disease

□ Liver Disease

□ Measles

□ Migraine Headaches

□ Miscarriage

□ Mononucleosis

□ Multiple Sclerosis

□ Mumps

□ Osteoporosis

□ Pacemaker

□ Parkinson’s Disease

□ Pinched Nerve

□ Pneumonia

□ Polio

□ Prostate Problems

□ Prosthesis

□ Psychiatric Care

□ Rheumatoid Arthritis

□ Rheumatic Fever

□ Scarlet Fever

□ Stroke

□ Suicide Attempt

□ Thyroid Problems

□ Tonsillitis

□ Tuberculosis

□ Tumors, Growths

□ Typhoid Fever

□ Ulcers

□ Vaginal Infections

□ Venereal Disease

□ Whooping Cough

□ Other_________

_______________

_______________

 

Dates of last exams ___________________________________________________________

Women Are you pregnant? □Yes □No  

Nursing? □Yes □No Taking birth control pills? □Yes  □No

List any types of surgeries which you have had and the dates which they occurred:

____________________________________________________________________________

Please list all medications you are currently taking: __________________________________

Allergies:_____________________________________________________________________

 

Daily Habits

What type of exercise do you perform on a daily basis?  

 □None              □Moderate                □Heavy

What do your daily work habits include?  (ex: sitting, standing, light labor, heavy labor, computer work)

___________________________________________________________________________

What vitamins do you currently take?____________________________________________

What kind of other nutritional supplements do you take (if any)? _______________________

Do you smoke?   □ No   □ Yes  How much per day?_______________

How much liquor do you consume on a weekly basis? _____________

How much coffee or caffeinated beverages do you consume on a daily basis?___________

 

Certifications and Assignment

To the best of my knowledge, the above information is complete and correct.  I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health.

 

I certify that I, and/or my dependent(s), have insurance coverage with _______________

                                                                                 Name of Insurance Company(ies)

and assign directly to Dr. _______________________ all insurance benefits, if any, otherwise payable to me and services rendered.  I understand that I am financially responsible for all charges whether or not paid by insurance.  I authorize the use of my signature on all insurance submissions.

 

The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.  This consent will end when my current treatment plan is completed or one year from the date signed below.

 _______________________________________________     _____________________

 Signature of Patient, Parent, Guardian or Personal Representative               Date

 _______________________________________________     _____________________

Please print name of Patient, Parent, Guardian or Personal Representative  Relationship to Patient