Patient Information

Patient Last Name:

First:

MI:

Address:

City:

State/Zip:

Home Phone:

Cell Phone:

# of Children:

SSN:

Patient DOB:

Age:

Marital Status:

Email Address:

Would you like text message and/or email reminders of your appointments?

If you would like text message reminders, please write your mobile carrier

Patient Occupation:

Employer:

Employer Address:

Work Phone:

Emergency Contact Information

Contact Name:

Relationship:

Address:

City:

State/Zip:

Home Phone:

Work Phone:

Cell Phone:

Insurance Information

Do you have insurance?

Would you like us to bill your insurance for you?

If yes to both questions, please provide us your card to take a copy of.

Referral/Purpose

How were you referred?

Purpose of this appointment

Have you ever had same/similar condition? Describe:

Days lost from work?

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 payers 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. If there is anyone that you do not want to receive your medical records, please inform the office.

Patient’s Signature: [signature]

Date:

Parent/Guardian Signature:[signature]

Date:

Case History

Review or Systems

Do you have skin, hair, or nail problems?

Do you have mouth and/or throat problems?

Do you have nose and/or sinus problems?

Do you have ear problems?

Do you have eye problems?

Do you have chest or lung (breathing) problems?

Do you Smoke?

Cigarettes per day?

How long have you smoked?

Do you have heart and/or blood vessel problems?

Do you have digestive problems?

Do you have genital problems? (Ex. Prostate, testicular, vaginal)?

Do you have urinary (including kidney or bladder) problems?

Do you have any gland and/or hormone problems?

Do you have allergy or immunity problems?

Do you have any muscle, tendon, or ligament problems?

Do you have any bone or joint diseases (Ex. osteoporosis, arthritis)?

Do you have any nervous system, disease and/or mental health problems?

Females Only

Have you had menstrual problems?

Have you ever taken birth control?

Is there any chance you could be currently pregnant?

Do you have any breast problems?

Past History

List any diseases that you have had in the past, including childhood disease:

Tell us if you have ever been diagnosed as having a particular condition such as diabetes, AIDS, ect.:

Have you suffered any physical injuries, such as falls or blows, auto accidents, whiplash, concussion or head
injury, lacerations, sprains, strains, dislocations, broken, or cracked bones?

List any surgeries you have had. (Including appendix, tonsils, ear tubes, and wisdom teeth):

Date:

Have you ever been hospitalized for any reason other than surgery?

Medications: Please list all prescriptions/non-prescriptions medication you are taking on a regular and/or occasional basis

Social History

In what position do you usually sleep and how well?

Do you exercise on a regular basis?

How do you spend your spare time?

Do you use:
Caffeine?Tobacco?Nicotine?Recreation drugs?Alcohol?

Please describe your work type:
Physical labor?Driver?

Clerical?Factory?Homemaker?

Describe your physical demands:
Heavy?Moderate?Mild?Sedentary?

Please describe your work stress level:
High?Medium?Low?

Family History

Are there any diseases or conditions that are common among your family members?

Additional Questions

Do you have a problem with recurring headaches?

Are you losing weight without trying?

Does your pain wake you up at night?

Have you had a sore throat that doesn’t heal?

Do you have indigestion or difficulty swallowing?

Have you had an obvious change in a wart or mole?

Do you have a nagging cough or hoarseness?

In the space below, please explain or give additional details reguarding the information you have given above.
Also, if there is any information about your health history that was not requested, please fill it in below:

Patient Health History

Patient Health History Continued

Do you currently have any of the following?

Current Treating Physicians

Primary Care Physicians:

Phone #:

OB/GYN:

Phone #:

Dentist:

Phone #:

Any Additional Information

Credit Guarantee Insurance Assignment & Personal Balance

Insurance Assignment: Our Insurance Assignment Program is designed to keep your out-of-pocket expenses to a minimum. As a courtesy to you, we will bill your insurance carrier on your behalf and wait up to 90 days for payment. Please remember, however, that you are ultimately responsible for payment. As a prerequisite,we ask that you leave a credit card to guarantee payment.

Filing Procedure: Claims for initial services are submitted within 48 hours after your visit. On day 90, if your insurance company had not paid the bill, we will change your designated credit card below for the amount of the claim. You will be sent a payment voucher. Any payments made on these claims thereafter will be immediately refunded to you. Please keep in mind this office will not bill your card without first trying to contact you.

Personal Balance: Estimated personal portions are paid at the time of service.

Difficulty urinating	Yes	No
Loss of bladder control	Yes	No
Loss of bowel control	Yes	No
Temporary loss of vision (one eye)	Yes	No
Blood in urine	Yes	No

Claustrophobia (fear of small spaces)	Yes	No
Spinal surgery	Yes	No
Common cold/flu	Yes	No
Carotid artery surgery	Yes	No
Breast removal	Yes	No

Detached retina	Yes	No
Stroke	Yes	No
Slipped disc	Yes	No
Herniated disc	Yes	No
Osteoporosis	Yes	No
Drop attacks	Yes	No
TIAis (pin or mini strokes)	Yes	No
Kidney disease	Yes	No
AIDS	Yes	No

Hardening of the arteries	Yes	No
Rheumatoid arthritis	Yes	No
Fractured/broken vertebra	Yes	No
Bleeding disorders	Yes	No
High blood pressure	Yes	No
Blood in stool	Yes	No
Cancer	Yes	No
Prostate Disease	Yes	No
Partial or complete paralysis	Yes	No

Pregnant	Yes	No
Taking birth control pills	Yes	No
Receiving hormone therapy (male)(female)	Yes	No
Receiving chemotherapy	Yes	No
Receiving radiation therapy	Yes	No
Taking blood thinners	Yes	No
Head Trauma	Yes	No
A heavy smoker (1 or more packs a day)	Yes	No
Surgical/medical implanted devices:	Yes	No
Aortic clips	Yes	No
Brain clips	Yes	No
Artificial heart valves	Yes	No
Rods, pins, screws	Yes	No
IUD	Yes	No
Surgical clips/wires	Yes	No
Shunt	Yes	No
Neurostimulator	Yes	No
Dentures	Yes	No
Pacemaker	Yes	No
Hearing aid	Yes	No
Insulin pump	Yes	No
Joint replacement	Yes	No
Cochlear implants (ear)	Yes	No
Other implanted devices:	Yes	No
Metal fragments	Yes	No
Bullets/shrapnel	Yes	No
Body piercing	Yes	No

Patient Information