Date        Doctor     ID size=28 name=Address> 

  City -->  State Zip size=12 name=Zip>

Home Phone: -->  Age       Birth Date b-value-required="TRUE" -->  Sex    M   F

Social Security #   Driver's License Number:

Personal Health Insurance #    Marital: M S W D       

Employer Type of work

Office Phone         

Name of Spouse    Spouse's Health Insurance #

Spouse's Employer       Office Phone

Type of Work        

Names & Ages of Children

     

Whom may we thank for referring you to our office?

Name & number of emergency contact Relationship:

Who is responsible for your bill, you and  spouse    Workers' Comp   Auto Insurance   Medicare

Insured Person's Name    Date of birth

Current Health Condition

Unwanted health condition -->

Other doctors seen for this conditions Yes   No   Who

Type of treatment    Results

When did this condition begin?    Has this condition occurred before? Yes   No 

Is condition: Job related   Auto accident   Home injury   Fall   Other:

Date of accident Time of accident

Have you made a report of your accident to your employer? Yes   No 

Drugs you take now: Nerve pills    Pain killers/muscle relaxers    Blood pressure medicine  Insulin

Other:

Do you wear a shoe lift? Yes   No 

Do you suffer from any condition other than that which you are now consulting us?

Caused by:

Past Health History

Major Surgery/Operations: Appendectomy     Tonsillectomy    Gall Bladder    Hernia    Broken Bone(s)   

       

Major Accidents or Falls:

Hospitalization (other than above):

Have you had previous chiropractic care? Yes    No Doctor's Name

Below is a list of conditions which may seem unrelated to the purpose of your appointment. However, these questions must be answered carefully as these problems can affect your overall diagnosis, treatment plan, and possibility of being accepted for care.

Please check any of the following diseases that you have had:

Pneumonia  Arthritis Chicken Pox         
Rheumatic Fever Tuberculosis Diabetes   
Polio  Whooping Cough Cancer                 
Anemia Heart Disease Epilepsy
Measles Thyroid Mental Disorder
Mumps         Influenza Lumbago
Small Pox   Pleurisy Eczema

 Have you tested HIV positive?  Yes     No

Please check any of the following you now have or have had in the past 6 months.

Musculoskeletal Code  Constipation Male/Female Codes
Low Back Pain  Hemorrhoids Menstrual Irregularity
Pain Between Shoulders Liver Trouble   Menstrual Cramping
Neck Pain Gall Bladder Problems Vaginal Pain/Infections
Arm Pain Weight Troubles Breast Pain/Lumps
Joint Pain/Stiffness Abdominal Cramps Prostate/Sexual Dysfunction
Walking Problems Gas/Bloating after Meals Genital Herpes
Difficulty Chewing/Clicking Jaw Heartburn Females only:
Nervous System Code  Black/Bloody Stool When was your last period?
Numbness  Colitis  Are you pregnant? Yes     No
Paralysis  Genitourinary Code  

Family History

Dizziness  Bladder Trouble The following have a same or similar problem:
Forgetfulness Painful/Excessive Urination Mother 
Confusion/Depression Discolored Urine Father
Fainting C-V-R Code Brother
Convulsions Chest Pain Sister 
Cold/Tingling Extremities Short Breath Spouse
General Code Blood Pressure Problems Child
Allergies    Irregular Heartbeat  
Loss of sleep Heart Problems  
Fever  Lung Problems/Congestion  
Headaches  Varicose Veins   
Gastrointestinal Code   Ankle Swelling  
Poor/Excessive Appetite    EENT Code  
Excessive Thirst Vision Problems   
Frequent Nausea Dental Problems  
Vomiting Sore Throat  
Diarrhea Earache   
Hearing Difficulty  
Stuffed Nose  

Do Not Tpye Between These Lines.

Analysis: ___________________________________________________________________

Diagnosis: _________________________________________________________________

Patient Accepted: Yes         No                                 ___________________________________

                                                                                                        Doctor's Signature

Benefits Assigned

I hereby authorize I ASSIGN ALL BENEFITS payable directly to the Doctors and I am financially responsible for all non-covered services.

Patient's Signature   Date

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that the Doctor's Office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to the Doctor's Office will be credited to my account on receipt. However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will be immediately due and payable.

I hereby authorize the Doctor to treat my condition, as he/she deems appropriate through the use of manipulation throughout my spine and also understand any risk associated with such manipulation. It is understood and agreed the amount paid the Doctor for x- rays is for examination only and the x-ray negatives will remain the property of this office, being on file where I may see them at anytime while a patient of this office. I also agree that I am responsible for all bills incurred at this office. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis.

Patient's Signature                    Date

Consent to Treat Minor             Date

Guardian or Spouse's Signature Authorizing Care   Date

 


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