Chiropractic Registration and History

CHIROPRACTIC REGISTRATION AND HISTORY

PATIENT INFORMATION
Date: ______
Patient:______
Address:______
______
City State Zip
Email :______
Sex: M F Age:______Birthdate:______
Single Married Widowed Separated Divorced
Patient SS#: ______
Occupation: ______
Employer: ______
Employer Address: ______
Employer Phone: ______
Spouse’s Name: ______
Birthdate: ______SS#:______
Occupation: ______
Spouse’s Employer: ______
Who may we thank for referring you? ______
/ ACCOUNT INFORMATION
Who is responsible for this account? ______
Relationship to Patient: ______
Birthdate: ______SS#: ______
INSURANCE
Subscriber’s Name: ______
Birthdate: ______SS#: ______
Relationship to Patient: ______
Primary Insurance: ______
Secondary Insurance: ______
ASSIGNMENT AND RELEASE
I, the undersigned certify that I (or my dependent) have insurance coverage with ______and assign directly to Dr. ______all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
Responsible Party Signature:
______
Relationship: Date:
______
PHONE NUMBERS
Home: ______Work/Cell:______
Best time and place to reach you: ______
IN CASE OF EMERGENCY, CONTACT:
Name: ______Relationship:______
Home: ______Work/Cell: ______/ ACCIDENT INFORMATION
Is condition due to an accident? Yes No Date: ______
Type of accident: Auto Work Home Other
To who have you made a report of your accident?
Auto Insurance Employer Worker Comp Other
Attorney Name (if applicable): ______
PATIENT CONDITION Reason for Visit: ______
When did your symptoms appear? ______Is this condition getting progressively worse? Yes No Unknown
Mark an X on the picture where you continue to have pain, numbness, or tingling.
Rate the severity of your pain on a scale from 1 (least pain) to 10 ( severe pain):_____
Type of pain: Sharp Dull Throbbing Numbness Aching Shooting
Burning Tingling Cramps Stiffness Swelling Other
How often do you have the pain? ______
Is it constant or does it come and go? ______
Does it interfere with your Work Sleep Daily Routine Recreation
Activities or movements that are painful to perform: Sitting Standing Walking Bending Lying Down
HEALTH HISTORY
What treatment have you already received for your condition? Medications Surgery Physical Therapy Chiropractic Services None
Other: ______
Name and Address of other doctor(s) who have treated you for your condition: ______
Dates of Last: Physical Exam:______Spinal X-Ray:______Blood Test: ______Dental X-Ray:______
Spinal Exam: ______Chest X-Ray: ______Urine Test: ______MRI, CT-Scan, Bone Scan:______
Please check the “Yes” or “No” to indicate if you have had any of the following:
Yes No
□ □ AIDS/HIV
□ □ Alcoholism
□ □ Allergy Shots
□ □ Anemia
□ □ Anorexia
□ □ Appendicitis
□ □ Arthritis
□ □ Asthma
□ □ Bleeding Disorder
□ □ Breast Lump
□ □ Bronchitis
□ □ Bulimia
□ □ Cancer
□ □ Cataracts
□ □ Chemical Dependency
□ □ Chicken Pox
□ □ Diabetes / Yes No
□ □ Emphysema
□ □ Epilepsy
□ □ Fractures
□ □ Glaucoma
□ □ Goiter
□ □ Gonorrhea
□ □ Gout
□ □ Heart Disease
□ □ Hepatitis
□ □ Hernia
□ □ Herniated Disk
□ □ Herpes
□ □ High Cholesterol
□ □ Kidney Disease
□ □ Liver Disease
□ □ Measles / Yes No
□ □ Migraine Headache
□ □ Miscarriage
□ □ Mononucleosis
□ □ Multiple Sclerosis
□ □ Mumps
□ □ Osteoporosis
□ □ Pacemaker
□ □ Parkinson’s Disease
□ □ Pinched Nerve
□ □ Pneumonia
□ □ Polio
□ □ Prostate Problems
□ □ Prosthesis
□ □ Psychiatric Care
□ □ Rheumatoid Arthritis
□ □ Rheumatic Fever / Yes No
□ □ Scarlet Fever
□ □ Stroke
□ □ Suicide Attempt
□ □ Thyroid Problems
□ □ Tonsillitis
□ □ Tuberculosis
□ □ Tumors, Growths
□ □ Typhoid Fever
□ □ Ulcers
□ □ Vaginal Infections
□ □ Venereal Disease
□ □ Whooping Cough
□Other ______
______
EXERCISE
None Moderate
Daily Heavy / WORK ACTIVITY
Sitting Standing
Light Labor Heavy Labor / HABITS
Smoking Packs/Day______
Alcohol Drinks/Week ______
Coffee/Caffeine Drinks Cups/Day______
High Stress Level Reason______
Are you pregnant? Yes No Due Date:______
Injuries/Surgeries you have had Description Date
Falls: ______
Head Injuries:______
Broken Bones: ______
Dislocations: ______
Surgeries: ______
MEDICATIONS
______
______
______
Pharmacy Name: ______
Pharmacy Phone:______/ ALLERGIES
______
______
______
______ / VITAMINS/HERBS/MINERALS
______
______
______
______