Patient Information

Please correct the errors described below.

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.

History of Present and Past Illness

Social History

Please indicate beside each activity whether you engage in it:

Family History

Please review the below-listed diseases and conditions and indicate those that are current health problems of the family member, which family member, and that family member's age. Leave blank those spaces that do not apply. Please add an (L) for any relative that lives around this local area, as some hereditary conditions are affected by similar climate.

Focus on the following family members: Father, Mother, Spouse, Brother(s), Sister(s), Children.

Example: Father, 72 (L)

I certify the information provided is accurate to the best of my knowledge:

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