Patient Information Form

Date

SS/HIC/Patient ID#

Patient First Name

Last Name

Middle

Address

City

State

Zip Code

Email address

Age

If Partnered, how many years?

Occupation

Patient Employer/School

Employer/School Address

Employer/School Phone Number

Spouse Name

Birthdate

SS #

Spouse Employer

Who may we thank for referring you?

INSURANCE

Who is responsible for this account?

Relationship to Patient

Insurance Co.

Group #

Is patient covered by additional insurance?

Yes No

Subscriber's Name

Birthdate

SS #

Relationship to Patient

Insurance Co.

Group #

ASSIGNMENT AND RELEASE

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

And assign directly to Dr.

all insurance benefits, if any, otherwise payable to me for 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.

Disclaimer: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Name / Signature of Patient, Parent. Guardian or Personal Representative

Date

Relationship to Patient

Phone Numbers

Home Phone

Cell Phone

Best time and place to reach you

IN CASE OF EMERGENCY, CONTACT

Name

Relationship

Home Phone

Cell Phone

ACCIDENT INFORMATION

Is condition due to an accident?

Yes No

If yes, Date?

Type of Accident

Auto

Work

Home

Other

If Other, Please Specify

To whom have you made a report of your accident?

Auto Insurance

Employer

Worker Comp.

Other

Attorney's Name (If applicable)

PATIENT CONDITION

Reason for Visit

When did your symptoms appear?

Is this condition getting progressively worse?

Yes

Unknown

Please specify which area where you continue to have pain, numbness, or tingling.

How often do you have this pain?

Is it constant or does it come and go?

Does it interfere with your

Work

Sleep

Daily Routine

Recreation

Activities or movements that are painful to perform

Sitting

Standing

Walking

Bending

Lying down

HEALTH HISTORY

What treatment have you already received for your condition?

Medications

Surgery

Physical Therapy

Chiropractic Services

None

Others

If Other, Please Specify

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

DATE OF LAST:

Physical Exam

Spinal X-Ray

Blood Test

Spinal Exam

Chest X-Ray

Urine Test

Dental X-Ray

MRI, CT-Scan, Bone Scan

Please select "Yes" or "No" to indicate if you have had any of the following

If Other, Specify

If Smoking , Packs/Day

If Alcohol, Drinks/Week

If Coffee, Cups/Day

If Stress, Reason

If yes, Due date?

Injuries/Surgeries you have had

Falls

Description

Date

Head Injuries

Description

Date

Broken Bones

Description

Date

Dislocation

Description

Date

Surgeries

Description

Date

MEDICATIONS

Pharmacy Name

Phone Number

ALLERGIES

VITAMINS / HERBS / MINERALS

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient's Name / Signature

Date

Your information will be encrypted.