Registration & History

Patient Information

Date

Full Name

Sex

Male Female

Birthdate

Social Security #

Phone

Cell

Home

Address

City/State/Zip

Would you like to be contacted by e-mail?

Yes No

Email address

Occupation

Employer

Spouse’s Name

Spouse’s Birth Date

Spouse’s Occupation

Who may we thank for referring you?

In case of emergency, contact:

Name

Relationship

Cell Phone

Home Phone

Insurance

Primary Insurance Co.

Secondary Insurance Co.

ASSIGNMENT AND RELEASE

I, the undersigned, certify that I (or my dependent) have insurance coverage with

and assign directly to Chiropractic Office 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 hereby authorize the doctor(s) to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

***Patient/Guardian Signature***

Relationship

Date

Is condition due to an accident?

Yes No

Date of accident

State

Type

Auto

Work

Home

Other

To whom have you made a report of your accident?

Auto Insurance

Employer

Patient Condition

What are your symptoms?

Date symptoms appeared

Cause of symptoms

Is this condition getting progressively worse?

Yes No Unknown

Your pain is:

Constant Occasional

It interferes with

Work

Sleep

Daily Routine

Recreation

Click any activities that are painful to perform:

Sitting

Standing

Walking

Bending

Lying Down

Other

List each area of pain (Neck, Back, etc.)

Add how severe is your pain today 0=No Pain, 10=Intolerable

Health History

Primary Care Physician

Specialist

Type

Date of Last:

Physical Exam

Spinal Exam

Blood Test

Click any treatments you have already received for this condition:

Medications

Surgery

Physical Therapy

Chiropractic Services

Other

Exercise

None Moderate Daily Heavy

Work Activity

Sitting Standing Light Labor Heavy Labor

Are you pregnant?

Yes No N/A

If yes, due date

Injuries/Surgeries you have had:

Medications:

Allergies:

I certify that the information on this form is correct to the best of my knowledge. I will not hold my doctor or any member of this office responsible for any errors or omissions that I may have made in the completion of this form. I understand that the doctor will be relying on the above information and all other information that I supply in his treatment of me. I hereby give permission to the doctor and whomever he may designate as his assistants to administer treatment and/or therapy, and perform such procedures as he may deem necessary in the diagnosis and/or treatment of my condition. I certify that no guarantee has been made as to the results that may be obtained.

Patient/Guardian Signature

Date

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Registration & History

Patient Information

In case of emergency, contact:

Patient Condition

Health History

Dr. Joe A. Cantu