CONFIDENTIAL PATIENT INFORMATION
Dear Patient:
Welcome to our office! We want you to know that it is our sincere desire to help you in any way we can. Please take the next few moments to complete this confidential questionnaire. The information you provide us will help us serve you more effectively. Thank you!
Date ______Name ______Sex: M or F
Social Security No. ______e-mail address ______
Street Address ______City ______State ______Zip Code ______
(Residence and Mailing)
Home Telephone (_____)______Cell Phone (_____)______Age _____ DOB ______
Marital Status: S M W D No. of Children ______Height ______Weight ______Driver’s License #______
Occupation ______FT, PT, Retired Work Telephone # (____)______ext. ______
Employer’s Name ______and Address ______
Spouse’s Name ______Spouse’s Work Telephone # (____)______ext. ______
Name of Nearest Relative ______Address______Phone (____)______
(not living with you)
Name of person responsible for payment ______Relationship ______
Do you have insurance that covers Chiropractic care? Yes ______No ______
Name of Insurance Company ______Policy No. ______
Name of Insured ______Date of Birth ______Relationship ______
If you're a patient that has been in a car accident and you have an attorney please list: Name ______
Address ______and Phone No. (_____)______of your Attorney
NOTE: If you have RECENTLY been involved in an accident or injury, please request and fill out our accident report form which may be obtained from the FRONT DESK.
WHO MAY WE THANK FOR REFERRING YOU TO US ______
List Chiropractors you have seen before:
1. Name ______Address ______Phone ______
When? ______What did he/she say was wrong? ______
2. Name ______Address ______Phone ______
When? ______What did he/she say was wrong? ______
What is your major complaint? ______
When did it begin? ______Is it getting: better _____ worse _____ same _____
Please rate your pain intensity (0=no pain, 10=most severe) ______
List your problems or complaints according Date started, or for If you've had the Did problem begin
to severity of pain how long condition before, when? with an injury?
1. ______
2. ______
3. ______
These conditions interfere with my: work ______personal care ______social life ______recreation ______
I have difficulty with: lifting ______walking ______standing ______sitting ______sleeping ______
Other ______
List Medical Doctors you have seen before:
1. Name ______Address ______Phone ______
When? ______What did he/she say was wrong? ______
2. Name ______Address ______Phone ______
When? ______What did he/she say was wrong? ______
Present family doctor ______Phone (____)______Date of last physical exam ______
Surgery(s):
1. Type ______When ______Doctor ______
2. Type ______When ______Doctor ______
3. Type ______When ______Doctor ______
4. Type ______When ______Doctor ______
Accidents and/or injuries: (Especially those related to your PRESENT problems).
1. Type ______When ______Doctor ______
2. Type ______When ______Doctor ______
3. Type ______When ______Doctor ______
Check the following conditions you may have had or do have now:
Allergy Depression HIV Neuritis Ulcers
Alcoholism Diabetes Irregular Periods Nervousness Venereal Disease
Anemia Eczema Low Blood Pressure Pleurisy Whooping Cough
Arteriosclerosis Emphysema Malaria Pneumonia
Arthritis Epilepsy Menstrual Cramps Polio
Asthma Gall Bladder Migraine Ringing in Ears
Backaches/Pain Gout Measles Rheumatic Fever
Cancer High Blood Pressure Miscarriage Stroke
Convulsion Heart Disease Multiple Sclerosis Sinus
Constipation Headaches Mumps Thyroid Problems
Cold Sores Heart Attack Neck Pain Tuberculosis
I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that McCarthy Family Chiropractic may 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 McCarthy Family Chiropractic 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.
By signing below, I consent to the videotaping of certain office procedures, including but not limited to adjustments, report of findings, and spinal care classes. I will always be notified in advance if I am to be videotaped. I also understand that the videotapes are for educational purposes only and are not for public viewing.
Patient’s Signature ______Date______
Guardian or Spouse’s Signature______Date______