Appointment

Patient Information

First Name ^*

Middle Name

Last Name ^*

Gender ^*

Date Of Birth ^*

Social Security #

Height

Weight

Marital Status

Spouse's Name

No of Children

Contact Information

Email ^*

Home Phone

Cell Phone

Work Phone

Country

Address Line 1

Address Line 2

City

State

Zip Code

How did you find out about our office?

Referring Physician

Referring Patient

Referred by

Did you hear about our office from an advertisement ?
No Yes

Did you hear about our office from a phone or professional directory ?

"If Yes," Where

Employment Information

Regular Work Status

Employer Name

Employer Address

Employer City

Employer State

Employer Zip

Occupation

Supervisor Name

Supervisor Phone/EXT

Physical Work Duties

Insurance & Payment for Care

Please only fill the insurance section that applies to you.

If You have personal health insurance please present the card to the front desk with a photo ID.

Injury due to car accident

Your Automobile Insurance Company

Claim No from your insurance company

Date of Injury:

Your insurance contact person

Phone No of Your insurance contact person

Attorney Name

Attorney Phone Number

Workers Compensation Company

Date of Injury:

Claim Number

Insurance contact person

Phone No of contact person

Name of Insurance Company

Date of Injury:

Claim Number

Insurance contact person

Phone No of contact person

Name of Insurance Company

Date of Injury:

Insurance Company Phone Number

Member ID Number

Group Number

State

Authorization

I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.

^* I agree with this statement of authorization

Current Symptoms

What is the purpose of your visit?

Please describe how the injury, pain, or discomfort originated

Where did the injury occur?

Date of Injury:

Does this condition interfere with any of your daily routines?

Select frequency you experience pain from this condition:

Has this condition affected your ability to sleep?

Please describe your pain/discomfort

Has this condition affected your appetite?

"If Yes," Explain

Have you reduced or limited your work hours because of this condition?

"If Yes," Explain

Is the pain/discomfort worse at certain times of the day?

"If Yes," Explain

Does the weather affect your pain/discomfort?

"If Yes," Explain

List anything that aggravates your condition

List anything that improves your condition

Have you received professional treatment for this condition?

"If Yes," Explain

Have you had X-rays taken for this condition?

"If Yes," Where?

Have you missed any work due to this injury?

"If Yes," Enter the first date of work you missed

Enter the date you returned to work

Pain level Rating - Scale 1 to 10 (Where 1 is least pain and 10 is maximum pain)

At its best
At its worst
Current Level

Have you ever had this same condition?

"If Yes," When?

Insurance & Payment for Care

How do you plan to pay for care?
Personal Insurance Third-Party Insurance No Insurance, Self-Pay

Name of Party Responsible for Payment

Responsible Party Phone

Primary Insurance

Insurance Name

Phone

Address

City

State

Zip

Id Policy

Group

Insured's Name

Insured's Date of Birth

Secondary Insurance

Insurance Name

Phone

Address

City

State

Zip

Id Policy

Group

Insured's Name

Insured's Date of Birth

If an auto accident, please provide

Claim #

Insurance Contact Person

Insurance Phone

Attorney's Full Name

Attorney's Phone

Personal Health History

Family/Primary Physician

Date of Last Physical Exam

Name of Physician Seen

Physician Phone

Physician City

Physician State

Physican Zip

Please list any health conditions that you have been treated for in the last year: (condition, cause, current/resolved)

Have you had previous chiropractic care?
No Yes

Condition(s) treated

Date of last chiropractic visit

Are you pregnant, or have you had any signs of pregnancy? (Female Only)
No Yes

Are you planning to get pregnant in the next 12 months? (Female Only)
No Yes

List current medications:(name, amounts, frequency, length of use, reason for use)

List current vitamins, minerals, supplements, or herbs:(name, amounts, frequency, length of use, reason for use)

Secondary Insurance

Please only fill the insurance section that applies to you.

If You have personal health insurance please present the card to the front desk with a photo ID.

Your Automobile Insurance Company

Claim No from your insurance company

Your insurance contact person

Phone No of Your insurance contact person

Attorney Name

Attorney Phone Number

Workers Compensation Company

Claim Number

Insurance contact person

Phone No of contact person

Name of Insurance Company

Claim Number

Insurance contact person

Phone No ofcontact person

Name of Insurance Company

Insurancy Company Phone Number

Member ID Number

Group Number

State

A. VEHICLE YOU ARE IN

B. OTHER VEHICLES INFO