Patient Information

Date field

Patient #

Doctor

Name

Social Security #

Home Phone

Address

City

State

Zip

E-mail address

Fax #

Cell Phone

Age

Birth Date

Race

Marital Status

Occupation

Employer

How many children?

Names and Ages of Children

Name of Nearest Relative

Relative's address

Relative's phone

How were you referred to our office?

Family Medical Doctor

Family Doctor Location

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

Please check any and all insurance coverage that may be applicable in this case:

Major Medical

Worker's Compensation

Medicaid

Medicare

Auto Accident

Medical Savings Account & Flex Plans

Other

Name of Primary Insurance Company

Primary Insurance ID #

Name of Secondary Insurance Company and ID # (if any)

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.

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. The following person(s) have my permission to receive my personal health information:

Patient's Electronic Signature of Acceptance (type full name)

Date

Guardian's Signature Authorizing Care

Date

History of Present and Past Illness

Purpose of this appointment

Date symptoms appeared or accident happened

Is this due to:

Auto Work Other

If other, please explain

Is this problem interfering with you:

Activities of daily living Work Social Activities Hobbies Sleep

Is your problem:

getting better staying the same getting worse

Does your problem occur:

occasionally

intermittantly

constantly

frequently

What aggravates your condition?

What relieves your condition?

Have you ever had the same or a similar condition?

Yes No

If yes, when and describe

Days lost from work:

Date of last physical examination

Do you have a history of stroke or hypertension?

Have you had any major illnesses, injuries, falls, auto accidents or surgeries? Women, please include information about childbirth (include dates):

Have you been treated for any health condition by a physician in the last year?

Yes No

If yes, describe:

What medications or drugs are you taking?

Do you have any allergies to any medications?

Yes No

If yes, describe:

Do you have any allergies of any kind?

Yes No

If yes, describe:

Do you have any Congenital Condition?

Yes No

If yes, describe:

Women: Are you pregnant?

Yes No

Please indicate conditions which you previously had, but no longer do.

Social History

Please indicate beside each activity whether you engage in it:
OFTEN= “O” SOMETIMES= “S” NEVER= “N”

Vigorous Exercise

Moderate Exercise

Alcohol Use

Drug Use

Tobacco Use

Caffeine

High Stress Activity

Family Pressures

Financial Pressures

Other Mental Stresses

Other (specify)

Please list any hobbies. Are they affected by your condition?:

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)

Arthritis

Asthma/Hay Fever

Back Trouble

Bursitis

Cancer

Constipation

Diabetes

Disc Problem

Emphysema

Epilepsy

Headaches

Heart Trouble

High Blood Pressure

Insomnia

Kidney Trouble

Liver Trouble

Migraine

Nervousness

Neuralgia

Pinched Nerve

Scoliosis

Sinus Trouble

Stomach Trouble

Other (please explain)

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

Name of Patient

Typed Signature of Patient/Legal Guardian

Date Signed

Your information will be encrypted.