First Name
Middle Name
Date of Birth
Social Security #
Height Feet
Inches
Weight
Spouse's Name
Emergency Contact:
Relationship
Phone
Contact Information
Email
Home Phone
Cell Phone
Work Phone
Address Line 1
Address Line 2
City
State/Province/Region
Zip/Postal Code
How did you find out about our office?
Referring Physician
Referring Patient
If Yes, Where
If Yes, Where
Current Symptoms
Date of Injury
Please Describe how the injury, pain, or discomfort originated:
Please describe your pain/discomfort:
If Yes, Explain
If yes
Select unable to work from date
Select day you have or will return to work
If Yes, Explain
If Yes, Explain
If Yes, Explain
List anything that aggravates your condition
List anything that relieves or improves your condition:
If Yes, Explain
If Yes, Where?
Pain level Rating - Scale 1 to 10 (Where 1 is least pain and 10 is maximum pain) At its best
At its Worst
Current Level
If Yes, When?
List other practitioners seen for this injury/condition
Personal Health History
Family/Primary Physician
Date of Last Physical Exam
Physician Phone
Name of Family Physician or Physician Seen
Physician City
Physician Zip
Please list any health conditions that you have been treated for in the last year:
(condition, cause, current/resolved) Separate details with "," comma as shown above.
Condition(s) treated
Date of last chiropractic visit
List current medications
(name, amounts, frequency, length of use, reason for use) Separate details with "," comma as shown above.
List current vitamins, minerals, supplements, or herbs
(name, amounts, frequency, length of use, reason for use) Separate details with "," comma as shown above.
Social History & Life Choices
Reason for this Visit
Describe the reason for this visit
Please briefly describe, including the impact it has had on your life.
If you're only here for chiropractic wellness services please skip this section.
Briefly Explain
When did this concern begin?
Briefly Explain
Briefly Explain
Doctor's Name
Type of Treatment
For Women Only
COMPLETE THIS SECTION ONLY IF YOU ARE (OR THE PATIENT IS) A WOMAN OVER 16 YEARS OF AGE.
Estimate the date of your most recent PAP/pelvic exam:
Date of last mammogram?
Date of Last Menstrual Period?
Health Problems & Concerns
Health Problems & Concerns
Other
Have you had any of these Cardiovascular Diseases? Please select all that apply.
Authorization
I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.
Signature
Finalizing Form
Send
