New Patient Form

PATIENT INFORMATION

Referred By

Last Name

First Name

Address

City

State

Zip

Email address

Home

Work

Cell

Age

Date of Birth

Sex

Male Female

SSN

Marital Status

S M D W

Spouse's Name

Primary Care Physician

Address

Telephone

Fax

WORKERS COMPENSATION/SCHEDULED LOSS INFORMATION

Employer

Occupation

Work Address

State

Zip

Business Phone

EXT

Fax

Do you have

Surgical Reports X-ray Reports MRI Reports

AUTO INJURY/WORK INJURY/ PERSONAL INJURY INFORMATION

Insurance Type

Auto Work Lien Other

If other, please specify.

Relationship to Insured

Self Spouse Child Other

If other, please specify.

Date of Injury

Describe how the injury occurred.

Which body part was injured?

Name of Ins. Company

Ins. Phone

Policy #

Claim #

WCB #

Did you report the injury?

No Yes

If so, to whom?

Hospitalized?

No Yes

Where?

Were you working at the time of the accident?

No Yes

Are you presently working?

No Yes

If no, dates lost from work

Names of other doctors seen for this injury

If auto injury, were you

Driver Passenger Pedestrian Other

If other, please specify.

# of people in your vehicle

Wore seatbelt?

No Yes

Did airbag inflate?

No Yes

Name of Attorney

Attorney Address

Attorney Phone

Attorney Fax

PRIVATE HEALTH INSURANCE INFORMATION

Insured's Name

Insured's SS#

Patient's relationship to insured

Self Spouse Child Other

If other, please specify.

Name of Insurance Co.

ID #

SECONDARY INSURANCE

Insured's Name

Insured's SS#

Name of Insurance Co.

ID #

A) I hereby authorize release of any medical information necessary to process this claim and request payment of insurance benefits either to myself or to the party who accepts assignment.

B) I authorize payment of any medical benefit from third parties for benefits submitted for my claim to be paid directly to this office. I authorize the direct payment to this office of any sum I now or hereafter owe this office by my attorney, out of proceeds of any settlement of my case and by any insurance company contractually obligated to make payment to me or you based upon the charges submitted for products and services rendered.

C) I have read and received a copy of the Authorization for Use and Disclosure of Protected Health Information and Financial Policy. I understand and agree that health and accident policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that this office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered will be immediately due and payable.

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 Signature

Date

Patient Name

Age

Date

Work Injury Auto Accident No Apparent Reason Trauma

Date

LOCATION OF PAIN

Left Right Both

The pain began when?

The Condition?

Improving Worsening Unchanged

PAIN INTENSITY

Which pain is the worst?

Back Neck Arm Leg

What is the pain intensity?

Mild Moderate Severe

WHAT MAKES SYMPTOMS BETTER?

Lying

Sitting

Stretching

Standing

Walking

Stationary

On the move

Other

If other, please specify.

Do you have any weakness in your arms/legs?

Yes No

Do you have any numbness in your arms/legs?

Yes No

Does your pain ever wake you from sleep?

Yes No

Does coughing or sneezing increase pain?

Yes No

Do you have any loss of bowel/bladder control?

Yes No

Do you experience?

Dizziness

Weight Loss

Headache

Fever

Constipation

Loss of Appetite

Insomnia

Drop Foot

How long can you:

Walk

Stand

Sit

Drive

Any previous neck/back history prior to this episode?

Previous treatment?

Chiropractic

Physical Therapy

Acupuncture

Anti-Inflammatory

Steroids

Pain Medication

Epidural Injection

Have you had…

X-Rays

MRI

CT Scan

EMG

Myelogram

Facility

Do you have any Medical Problems?

Have you ever had any Major Surgeries?

What medications are you currently taking?

Are you on any blood thinners?

Are you allergic to any medications?

Any History of Cancer in your family?

Yes No

Do you Smoke?

Yes No

Do you Drink Alcohol on a regular basis?

Yes No

What type of work do you do?

Do you have any Children?

What type of exercise do you do?

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