Please fill out the following information then print, sign, date it
and bring it to your first appointment.
Thank You.
Welcome
About You
Today's Date:   File Number:
Patient Name:
 
Last
First
Mi
What you prefer to be called:   Gender:
Birthdate:   Age:   SSN:
Mailing Address:
City: State: Zip:
Home Phone #:   Work Phone #: ext.
Mobile Phone #:   Other Phone #:    
Email Address:
Referred By:
Employer:   How Long:
Employer's Address:
City: State: Zip:
Occupation:
Status:
Spouse's Name:
Do you have children:   How many?
Insurance Information
Company Name:
Address:
City: State: Zip:
Phone #:   Insured's ID #:
Group # (Plan, Local or Policy #):
Insured's Name:
Relation:   Date of Birth:
Insured's Employer:
Please inform desk of additional insurance sources.
Reason For Visit
The reason for this visit is a result of:
Explain what happened:
 
Explain the pain & its location:
 
When did the condition begin:
Is this condition getting worse?
Is this condition interfering with your  ?
If so, please explain:
Have you been treated by a Medical Physician for this condition?
If so, where?
Have you ever been treated by a Chiropractor before?
If so, whom?   Phone #:
In Event of Emergency
Who should we contact?
Relation:
Home Phone #:   Work Phone #: ext.
Who is your Medical Doctor?
Phone #:
Health History
Are you taking any of the following medications?
 
Do you have or ever had any of the following diseases or conditions?
 Heart Attack / Stroke    Heart Surgery / Pacemaker
 Heart Murmur    Congenital Heart Defect
 Mural Valve Prolapse    Artificial Valves
 Alcohol / Drug Abuse    Venereal Disease
 Hepatitis    HIV+ / Aids
 Shingles    Cancer
 Frequent Neck Pain    Emphysema I Glaucoma
 Anemia    High/Low Blood Pressure
 Psychiatric Problems    Rheumatic Fever
 Severe/Frequent Headaches    Kidney Problems
 Ulcers / Colitis    Fainting/Seizures/Epilepsy
 Sinus Problems    Asthma
 Diabetes/Tuberculosis    Difficulty Breathing
 Chemotherapy    Lower Back Problems
 Artificial Bones / Joints    Arthritis
Please list any other serious medical condition(s) you have or ever had:
Please list anything that you may be allergic to:
List previous surgeries/treatments with dates:
List any past serious accidents with dates:
Family Health History:
Do you: Take Supplements or Vitamins?   Exercise?
Are you one a special diet?   Since:
Do you smoke?   How Much? packs/day   How Long? years
Are you wearing:
What is the age of your mattress? years   Is it comfortable?
For women: Are you taking Birth Control?
Are you Pregnant?   How Long? months   Nursing?
Account Information
Person ultimately responsible for account
Name:
Relation:
Billing Address:
City: State: Zip:
SSN:   D.L.#:
Work Phone #:
Payment method:      
Enter card # (If accepted)    Initials:  
I hereby authorize assignment of my insurance rights and benefits directly to the provider for services rendered. I fully understand I am solely responsible for any balance not paid by my insurance company (if offered at this office).

  • We invite you to discuss with us any questions regarding our services. The best health services are based on a friendly, mutual understanding between provider and patient.
  • Our policy requires payment in lull for all services rendered at the time of visit, unless other arrangements have been made with the business manager. If account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, and any other expenses incurred in collecting your account.
  • I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider and or managed care organization, to release any information required to process insurance claims.
  • I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided.
Signature
Date
Adult Patient Parent Guardian Spouse