Patient Update Form

Please complete Parts A & C in all cases. Part B should be completed only if the information has changed since you were last in our office.

Part A

Name

Phone

Email Address

Fax #

Cell Phone

Street/Mailing Address

Purpose of this appointment:

Is this the same problem you were originally under care for?

Yes No

If yes, are there any additional symptoms?

Other doctors seen for this condition:

What medications or drugs are you taking?

Family Doctor.

Family Doctor City and state

When doctors work together it benefits you. May we have your permission to update your medical doctor regarding your care at this office?

YES NO

Part B

Occupation

Employer

Employer's address

Work Phone

Spouse

Spouse's Employer

Part C

AUTHORIZATION AND RELEASE: I authorize payment of insurance benefits directly to the chiropractor or chiropractic office. I authorize the doctor to release all information necessary to communicate with personal physicians and other healthcare providers and payors and to secure the payment of benefits. I understand that I am responsible for all costs of chiropractic care, regardless of insurance coverage. 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. I understand that interest is charged on overdue accounts at the annual rate of (16%).

The patient understands and agrees to allow this chiropractic office to use their Patient Health Information for the purpose of treatment, payment, healthcare operations, and coordination of care. We want you to know how your Patient Health Information is going to be used in this office and your rights concerning those records. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent. If there is anyone you do not want to receive your medical records, please inform our office.

Date Signed

Type full name as signature

Health Insurance Coverage?

Yes No

If NO, ask about our Time of Service Discounts

Company

Insurance Id #

Social Security Number

Date of Birth

What is your major symptom/complaint?

when did the problems begin?

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?

How frequent is the condition?

Constant Daily Intermittent Night Only With Movement

How long does it last?

All Day Few Hours Minutes

Are there any other conditions or symptoms that may be related to your major symptom?

Yes No

If yes, describe

Describe the pain.

Sharp Dull Numbness Tingling Aching Burning Stabbing Other

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?

What makes the problem worse?

Standing Sitting Lying Bending Lifting Twisting Other

Have you had any broken bones?

Yes No

If yes, please list and give dates:

List any major accidents you have had other than those that might be mentioned above:

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

WOMEN ONLY: Are you pregnant or is there any possibility you may be pregnant?

Yes No Uncertain

Date of last menstrual period

Remarks

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