CHIROPRACTIC REGISTRATION

PATIENT INFORMATION

Date

Patient Last Name

First Name

Middle Initial

Address:

E-mail

City

State

Zip

Sex

M F

Age

Birthdate

Status

Married Separated Widowed Divorced Single Minor Partnered

Are you pregnant?

Yes No

Due Date

Patient Employer / School

Occupation

Employer/School Address

Spouse's Name

Birthdate

SS #

Spouse's Employer

How were you referred to our office?

INSURANCE INFORMATION

Insurance Company

Subscriber's ID

Group #

Subscriber's Name

Birthdate

Subscriber's Employer

Relationship to Patient

Insurance Company Phone Number

Provider/Customer Service Line

Is patient covered by additional insurance? If yes, please fill out below

Yes No

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ASSIGNMENT AND RELEASE

I certify that I, and/or my dependent(s), have insurance coverage with and assign directly to Dr. Al Glaza

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.

Signature of Patient, Parent, Guardian or Personal Representative

Please print name of Patient, Parent, Guardian or Personal Representative

Birthdate

Relationship to Patient

PHONE NUMBERS

Cell Phone

Home Phone

IN CASE OF EMERGENCY, CONTACT

Name

Relationship

Home Phone

Work Phone

ACCIDENT INFORMATION

Is condition due to an accident?

Yes No

Date

Type of accident

Auto Work Home Other

Other:

Attorney Name

PATIENT CONDITION

Reason for Visit

When did your symptoms appear?

Is this condition getting progressively worse?

Yes No

Please describe exactly where you feel the pain

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

What treatment have you already received for your condition?

Medications

Surgery

Physical Therapy

Chiropractic Services

None

Other

If other, please specify:

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

Date of Last:

Physical Exam

Spinal Exam

Spinal Xray

Chest Xray

MRI, CT Scan, Bone Scan

What do you feel caused your condition?

What aggravates your condition?

What relieves your condition?

Does your pain radiate to any other parts of your body? (arms/legs)

Do you have numbness or tingling anywhere?

Have you seen any others doctors for this condition?

If so, When?

What treatment did you receive?

Who is your primary physician?

What have you done at home for this condition?

Results?

When was your last chiropractic adjustment?

With Dr.?

What were you treated for?

Results?

Any auto accidents in your history?

Do you have any heart conditions? (Pacemaker etc...)

Have you missed any days of work due to this condition?

How many so far?

Do you suffer from foot arch pain, no arch or plantar fasciitis?

Do you wear foot orthotics?

Privacy Notice

Acknowledgement of Receipt of Notice Of Privacy Practice

I have received a copy of this office's Notice of Privacy Practices.

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

Sign

Date

List any person(s) that may have access to your personal information.Appointments, Finances Treatments etc.

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Select "Yes" on any that apply to you or leave blank if "No".

Other:

EXERCISE

None

Light

Moderate

Heavy

WORK ACTIVITY

Sitting

Standing

Light Labor

Heavy Labor

HABITS

Current smoker

Former smoker

Never smoker

High stress level

If High stress level, Reason:

Injuries/Surgeries you have had

Falls

Description

Date

Head Injuries

Description

Date

Broken Bones

Description

Date

Dislocations

Description

Date

Surgeries

Description

Date

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Neck Pain

If you are experiencing neck pain, please answer the questions below:

This questionnaire has been designed to give the doctor information as to how your neck pain has affected your ability to manage in everyday life. In each section, please fill in ONE circle only which most closely describes your problem.

Section 1 - Pain Intensity

A. No pain at the moment B. Mild pain at the moment. C. Moderate pain at the moment. D. Fairly severe pain at the moment. E. Very severe pain at the moment. F. Worst imaginable pain at the moment.

Section 2 - Personal Care

A. Personal care is normal without extra pain. B. Personal care normal with extra pain C. Personal care painful/slow and careful. D. Manage most personal care with some help. E. Needs help everyday in most aspects of care. F. Difficulty dressing and washing/stays in bed.

Section 3 - Lifting

A. Lifts heavy weights with no pain. B. Lifts heavy weights with pain. C. Can lift heavy weights from a table. D. Can lift light weights from a table. E. Can lift only very light weights. F. Cannot lift or carry anything.

Section 4 - Reading

A. No pain while reading. B. Slight pain while reading. C. Moderate pain while reading. D. Moderate pain prevents reading. E. Severe pain prevents reading. F. Cannot read at all.

Section 5 - Headaches

A. No headaches. B. Slight, infrequent headaches. C. Moderate, infrequent headaches. D. Moderate, frequent headaches. E. Severe, frequent headaches. F. Constant headaches.

Section 6 - Concentration

A. Can concentrate without difficulty. B. Can concentrate with slight difficulty. C. Can concentrate with fair difficulty. D. Can concentrate with a lot of difficulty. E. Can concentrate with extreme difficulty F. Cannot concentrate at all.

Section 7 - Work

A. Work is unrestricted. B. Can do usual work, but no more. C. Can do most usual work, but no more. D. Cannot do usual work. E. Can hardly do any work. F. Cannot do any work.

Section 8 - Driving

A. Can drive without pain. B. Driving causes slight neck pain. C. Driving causes moderate neck pain. D. Cannot drive long due to moderate pain. E. Can hardly drive due to severe pain. F. Pain prevents driving.

Section 9 - Sleeping

A. No difficulties sleeping. B. Sleep is mildly disturbed. C. 1-2 hours loss of sleep. D. 2-3 hours loss of sleep. E. 3-5 hours loss of sleep. F. 5-7 hours loss of sleep.

Section 10 - Recreation

A. Recreation is not affected. B. Some neck pain, but does not affect activity. C. Some activity is affected by pain. D. Most activity is affected by pain. E. Activity severely restricted by pain. F. Cannot do any activity.

Mid and Lower Back Pain

If you are experiencing back pain, please answer the questions below:

This questionnaire has been designed to give the doctor information as to how your lower back pain has affected your ability to manage in everyday life. In each section, please fill in ONE circle only which most closely describes your problem.

Section 1 - Pain Intensity

A. Pain comes and goes and is mild. B. Pain is mild and does not vary. C. Pain comes and goes and is moderate. D. Pain is moderate and does not vary much. E. Pain comes and goes and is severe. F. Pain is severe and does not vary much.

Section 2 - Personal Care

A. Does not change habits to avoid pain. B. Does not change habits/Some pain. C. Does not change habits/Increases pain. D. Changes habits/Increases pain. E. Unable to do some personal care without help. F. Unable to wash or dress without help.

Section 3 - Lifting

A. Lifts heavy weights with no pain. B. Lifts heavy weights with pain. C. Cannot lift heavy weights off the floor. D. Can lift heavy weights from a table. E. Can lift light weights from a table. F. Can lift only very light weights.

Section 4 - Walking

A. Pain does not prevent walking. B. Cannot walk more than one mile. C. Cannot walk more than 1/2 mile. D. Cannot walk more than 1/4 mile. E. Can walk only with crutches. F. Bedridden and must crawl to the toilet.

Section 5 - Sitting

A. Can sit in any chair as long as desired. B. Can sit only in the favorite chair as long as desired. C. Can sit no more than one hour. D. Can sit no more than 1/2 hour. E. Can sit no more than 10 minutes. F. Cannot sit at all due to pain.

Section 6 - Standing

A. Can stand for an unlimited time without pain. B. Some pain standing/doesn't increase with time. C. Cannot stand for more than one hour. D. Cannot stand for more than 1/2 hour. E. Cannot stand more than 10 minutes. F. Cannot stand at all.

Section 7 - Sleeping

A. No pain in bed. B. Gets pain in bed, but sleeps well. C. Normal sleep reduced by 1/4. D. Normal night's sleep reduced by 1/2. E. Normal night's sleep reduced by 3/4. F. Cannot sleep at all due to pain.

Section 8 - Traveling

А. Travel without pain. B. Travel causes some pain, but not made worse. C. Causes extra pain/No change in form. D. Causes pain/Uses alternate travel. E. Pain restricts all forms of travel. F. Pain restricts travel except lying down.

Section 9 - Social Life

A. Normal and causes no pain B. Normal but causes extra pain. C. Limits energetic interests. D. Pain limits/doesn't go out as often. E. Pain restricted social life to home. F. Pain restricts all social life.

Section 10 - Changing Degree of Pain

A. Pain is rapidly improving. B. Pain fluctuates but is improving. C. Improvement is slow. D. Pain level is unchanged. E. Pain is gradually worsening. F. Pain is rapidly worsening.

I understand that the information I have provided above is current and complete to the best of my knowledge.

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

Signature:

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