About Patient

First name :

Last name :

Sex :

Male Female

SS# :

Birthdate :

Age :

Ethnic Origin/Race :

Address :

City :

State :

Zip :

Phone # :

Email :

Occupation :

Employer :

Marital Status :

# of children :

If patient is a minor :

Yes No

Who may we thank for referring you to our office :

Reason For Visit

Please describe the pain & its location :

The pain is a result of :

When did the pain begin?

Is the pain getting worse?

Yes No

Have you had this or a similar condition in the past ?

Yes No

Have you been treated by another physician for this condition ?

Yes No

Have you ever been treated by a chiropractor before ?

Yes No

Name of your family doctor :

Family Doctor’s # :

Health History

Cigarettes :

Yes No

Alcohol :

Yes No

Coffee :

Yes No

Exercise :

Yes No

Are you Pregnant ?

Yes No

Are you taking any medications ?

Yes No

Do you have or ever had any of the following condition or diseases ?

Heart Attack/Stroke :

Yes No

Cancer :

Yes No

Diabetes :

Yes No

Tuberculosis :

Yes No

Frequent Neck Pain :

Yes No

Psychiatric problems :

Yes No

Difficulty breathing :

Yes No

Sever/frequent headaches :

Yes No

Sinus Problems :

Yes No

Lower Back Problems :

Yes No

Fainting/seizures :

Yes No

Asthma:

Yes No

Artificial bones/joints :

Yes No

Please list any other serious medical condition(s) you have or had :

List previous/past surgeries/treatments with dates :

Family History: Headaches, Low Back Pain, Neck Pain, Other spinal problems, explain :

Assignment & Release

*I understand & agree that health & accident insurance policies are an agreement between an insurance carrier & myself. Furthermore, I understand that this office will prepare any necessary reports & forms to assist me in making collection from the carrier & that any amount authorized to be paid directly to this doctor’s office will be credited to my account upon receipt.

*As a courtesy to you we will verify your health care benefits for this office. You will then be responsible for any co pays and deductibles.

*Your health insurance is a contract between you & the insurance carrier. In the “rare” event that your insurance company is in “bad faith” & after our office makes every attempt to have all claims paid, we will have you, the patient, be responsible for contacting your insurance carrier to have the claims paid.

*If your insurance company has not paid within 120 days of billing, then you will be responsible to pay the balance due.

*If collection efforts become necessary to enforce payment terms, the patient agrees to pay all collection costs, attorney’s fees & other costs associated with collecting this balance.

*I hereby authorize the doctor & staff, to administer treatment, physical examination, x-rays studies, chiropractic care or any clinic services that he/she deems necessary in my case; I furthermore authorize him/her to disclose all or any part of my patient record to an y person or corporation which is or may be liable under a contract to this office or to patient or to a family member or employer of the patient for all or part of the clinic’s charge, including & not limited to hospital or medical services companies, welfare funds or the patient’s employer.

HAVE AUTOMOBILE ACCIDENT HISTORY ?

Yes No

AUTOMOBILE ACCIDENT HISTORY

Patient Name:

Date :

Time of accident:

State:

Who was cited for accident :

Was the vehicle a company car ?

Yes No

Did the accident happen while on company time ?

Yes No

Your vehicle was a:

Compact Mid-size Full-size Truck Full truck Van SUV

Other vehicle was a:

Compact Mid-size Full-size Truck Full truck Van SUV

What were the road conditions at time of accident:

Where was your car struck ?

Front Rear R-side L-side Full truck Van SUV

What is the estimated damage to your vehicle:

Total Loss::

Yes No

You were heading ?

North South East West
On :

Other vehicle was heading ?

North South East West
On :

Please explain in detail how your accident occurred ?

Number of people in the car including yourself ?

Your position in the car ?

Driver Passenger

If you were the passenger which seat were you in ?

Front Seat Right Side Back Seat Left Side Back Seat Right Side

How fast was your vehicle moving upon impact ?

MPH

STOPPED

How fast was the other vehicle(s) moving upon impact ?

MPH

STOPPED

Were the brakes applied at the time of impact ?

Yes No

Did the seat break at the time of impact ?

Yes No

Did the airbags deploy at the time of impact ?

Yes No

Were your seatbelts on at the time of impact ?

Yes No

Were the Police notified ?

Yes No

Did your head strike the windshield or any objects ?

Yes No

Did you feel pain immediately after the accident ?

Yes No Later that day Next day When?

What were your immediate symptoms after the accident ?

Have you ever had any complaints in the involved area before ?

Yes No

Since the injury, are your symptoms

Improving Getting Worse The Same

Did you lose consciousness at the time of the accident ?

Yes No

Where did you go after the accident ?

Work Home Hospital Chiropractor Family Doctor

If you sought Medical care, where did you go ?

If you sought Medical care, how did you get there ?

Self Friend Ambulance Helicopter

Have you retained an attorney ?

Yes No

Name

Cell

Printed Name:

Date :

If patient is a minor, please provide parent or guardian’s information.

Guardian Name :

   

Relationship :

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I, ______________________________, have received a copy of this office’s Notice of Privacy Practices.

If patient is a minor, please provide parent or guardian’s information.

Guardian Name :

   

Relationship :

CANCELLATION/MISSED APPOINTMENT POLICY

Your appointment time has been set aside for you. This time is unavailable to other patients. Therefore, we require at least 24 hours advance notice if you need to cancel your appointment. For all missed or cancelled appointments with less than 24 hours notice, you will be charged a $ 75.00 cancellation fee. Appointment reminder calls/emails are a courtesy. Should you not receive a reminder telephone call/email, it is still your responsibility to remember your appointment.

I, ______________________________, have read and understand the cancellation/missed appointment policy.

If patient is a minor, please provide parent or guardian’s information.

Guardian Name :

   

Relationship :