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Please print this form using the print function of your browser. You can then complete and sign the form to bring with you to your first appointment. This form will not be submitted via the Internet, so security is not an issue.
CONFIDENTIAL PATIENT INFORMATION Date________________ Name_____________________ Social Security_____________________ Home Phone___________ Cellular Phone__________________________ E-mail Address__________________________ Address_____________________________ City______________________ State _____ Zip_________ Age______ Birth Date_________________ Marital: M S W D How Many Children?_______________ Occupation __________________________ Employer _________________________________________ Address_______________________________________________ Office Phone ____________________ Student at ______________________________________ Full Time __________ Part Time ___________ Name of Husband or Wife _________________________ Occupation _____________________________ Employer ____________________________ Address _________________________________________ Name of Nearest Relative _______________ Address_______________________ Phone _____________ Referred by ___________________________________________________________________________ Is the condition due to injury or sickness arising out of employment?_______________________________ Is the condition due to injury or sickness arising out of auto or other accident? ______________________ Number of days lost from work _______ Date symptoms appeared or accident happened______________ Have you ever had the same or a similar condition? Yes ___ No ___ If yes, when and describe: _____________________________________________________________________________________ Date of last physical examination __________________________________________________________ What operations have you had? _____________________________ When? _______________________ Serious illness ___________________________________________ When? _______________________ Have you ever suffered from:
Purpose of this appointment ______________________________________________________________ Other doctor seen for this condition ________________________________________________________ Have you been treated for any health condition by a physician in the last year? YES NODescribe______________________________________________________________________________ What medications or drugs are you taking? __________________________________________________ Family Medical Physician ________________________________________________________________
I understand and agree that health and accident insurance policies are an arrangement between my insurance company and myself – not between my insurance company and this office. I understand my insurance company & this chiropractic clinic has given NO guarantees of coverage/payment. I also understand that all claims submitted are subject for review by my insurance company. I authorize this chiropractic clinic to release any medical information and to complete any usual and customary reports and forms to assist in collecting from my insurance company. If mine is a regular health insurance case, I agree to pay a percentage of services as they are rendered. However, I understand that I am ultimately responsible for payment in full at this office. I also understand that if I suspend or terminate my schedule of care as determined by my treating doctor, any fees for professional services will be immediately due and payable. HEALTH INSURANCE: (circle one) YES NO COMPANY____________________________________________ Do you need a referral to utilize your insurance benefits? (CIRCLE ONE) YES NO NOT SURE NOTE: ALL HMO/QPOS/POS CONTRACTS REQUIRE REFERRALS – ONLY EXCEPTION IS HMOBLUE & PPO CONTRACTS. Patient’s Signature _____________________________________________ Date _________________________ Guardian’s Signature Authorizing Care _____________________________ Date _________________________ 1. What is your major symptom? _____________________________________________________ 2. If this is a recurrence, when was the first time you noticed this problem?____________________ How did it originally occur?________________________________________________________ Has it become worse recently? Yes ___ No ___ Same ___ Better ___ Gradually Worse _____ If yes, when and how? ____________________________________________________________ 3. How frequent is the condition? Constant _____ Daily ____ Intermittent ____ Night Only ___ How long does it last? All Day _________ Few Hours ___________ Minutes _______________ 4. Are there any other conditions or symptoms that may be related to your major symptom? Yes _____ No _____. If yes, describe _____________________________________________ Are there other unrelated health problems? Yes _____ No _____. If yes, describe ___________ 5. Describe the pain: Sharp _____ Dull_____ Numbness _____ Tingling _____ Aching _____ Burning _____ Stabbing _____ Other _______________________________________________ 6. Is there anything you can do to relieve the problem? Yes ___ No ___. If yes, describe ______ ____________________. If no, what have you tried to do that has not helped? ______________ ______________________________________________________________________________ 7. What makes the problem worse? Standing ____ Sitting ______ Lying ______ Bending _____ Lifting _____ Twisting _____ Other ________________________________________________ 8. Have you had any broken bones? Yes ____ No ____. If yes, please list
and give dates 9. List any major accidents you have had other than those that might be mentioned above: _______ ______________________________________________________________________________ 10. To your knowledge, have you had any diseases, major illnesses, or injuries not indicated on this form either in the past or the present? Yes ____ No ____. If yes, please explain __________ ______________________________________________________________________________ 11. Remarks: ____________________________________________________________________ ______________________________________________________________________________ NO SYMPTOMS EXTREME SYMPTOMS ____________________________________________________________________ 1 2 3 4 5 6 7 8 9 10 How bad is your pain? (Circle a number)12. WOMEN ONLY: Are you pregnant or is there any possibility you may be pregnant? Yes _____ No _____ Uncertain _____ Reviewed by doctor- Doctor’s Signature ____________________________ Date _____________ Return to home page |
