Chiropractic Client Intake Form

Patient Questionnaire & Record

Patient Information

First Name:

Last Name:

Date

Date of Birth:

Social Security #:

Marital Status:

Married Single Divorced Widowed

Email Address:

Address (Home):

City:

State

Zip Code:

Sex

Age

Phone (Mobile):

Phone (Home):

Cell Carrier (to receive appt reminders)

Occupation

Height

Weight

Left or right handed?

Employer Name:

Referred By:

Referral location

Friend/Family Doctor/Medical Professional Internet Insurance Company

Please describe the reason(s) for your visit (i.e. neck pain, headaches, back pain, leg pain)

Approximate date problem began:

Have you had the same or similar condition before?

Is your condition due to an accident (home, personal, auto, work)?

If yes, where and how did it happen?

Other doctor or hospital seen for THIS condition:

When?

Where?

Describe type of treatment given:

Have you had an MRI/CT/Bone Scan or Xrays in the last three years?

Yes No

If yes, what area of your body? At what facility?

Have you had previous chiropractic treatment?

Yes No

When?

Dr.?

Name of Family Doctor

All over the counter medication for this condition:

All current prescription medications.

List all operations/surgeries and date performed.

Breast implants?

Yes No

Pacemaker?

Yes No

Fractures/broken bones

Do you suffer from any other disabling conditions or physical impairments not due to this illness or accident? If so, explain:

Pregnant?

Yes No

Family History (check those that apply)

Heart Disease

Cancer

Arthritis

Diabetes

Review of Systems

Do you presently have any problems related to the following systems? Please check if yes:

Psychological

Are you generally satisfied with your life?

Do you feel severely depressed?

Have you considered suicide?

Other

If other, describe here:

Insurance Information

Are you covered by Medicare?

Yes No

Do you have group/personal health insurance?

Yes No

Name of Insurance Company

Policy Number

Please have receptionist make a copy of your insurance card.

Your information will be encrypted.

Chiropractic Client Intake Form

Patient Questionnaire & Record

Patient Information

Review of Systems

Insurance Information

Please have receptionist make a copy of your insurance card.

Faircloth Chiropractic Clinic