New Patient Application (Chiropractic)

Hermann Wellness

Hermannwellness.com

309 663-2423

This form is HIPAA compliant. It is encrypted and can only be read by Dr Hermann and staff.

First Name

Last Name

Street Address

City, State Zip Code

Date of Birth

Phone number

Email address

Are we billing?

Patient pay

Health insurance

Auto accident

Workers Compensation

Marital Status

Married

Single

Divorced

Widowed

Who is responsible for the bill?

Policy Number

Group number

Policy Holder

Referred By:

Other patient

Your medical doctor

Internet

Other

Another chiropractor

Please tell us about you first problem area. Example: When did it start? What makes it better or worse? Does it radiate down the arm or leg?

Mark the areas on the image where you are experiencing symptoms

Please tell us about your second complaint.

Do you have any other health problems or conditions? Please list all.

How has this condition affected your life? Your home life? Occupational life? Recreational life? Rest and sleep? Please be specific.

Have you had any previous treatment? Please list doctors.

Please list any previous diagnostic tests. Example: xrays, MRI's, CT scans, physical therapy etc.

Please list your previous surgeries. (if applicable)

Please list your medications. Include any nutritional supplements and over the counter medication. List dosage.

Please list your medication allergies.

Do you have a family history of any of the following?

Back pain

Arthritis

Diabetes

Cancer

Cardiovascular Disease

Please list any other concerns or infomation you want the doctor or staff to know.

Your information will be encrypted.