KAISK COMMUNITY CHIROPRACTIC
1327 Canton Rd. Suite B
Akron, OH 44312
(234)-813-9200
kaiskchiro.com
CONFIDENTIAL PATIENT INFORMATION
Name:
Address: ______City: ______State: ____ Zip:
Cell Phone: ______HomePhone: ______Work Phone:
Personal Email: ______Birth Date: ______Age:
Marital Status: Married / Single / Other
Social Security Number: ______How did you learn about our office?:
Occupation: ______Employer:
Name of Spouse:
Spouse’s Employer:Spouse’s Occupation:
Spouse’s Phone Number:Spouse’s Health Status:
Emergency Contact Name:
Phone Number: Relation to you:
PAYMENT INFORMATION
Insurance Company Name:Card Holder Name:
Policy Number:Group Number:
I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and me. Furthermore, I understand that Kaisk Community Chiropractic will 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 Kaisk Community Chiropractic will be credited to my account on receipt. However, I clearly understand and agree that any services rendered to 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 to me will be immediately due and payable.
Patient Signature: ______Date:
Guardian or Spouse Signature: ______Date:
Name: ______Date:
CURRENT COMPLAINTS
What is the purpose for today’s visit:
Is your visit related to a/an: Automobile Accident / WorkInjury / Other:
Please describe any injury:
Date of injury (if applicable): Date your current symptoms appeared:
Have you received treatment for your current symptoms: Yes / No
If yes, explain:
Have you been under chiropractic care beforeYes / No If yes, when was your last treatment:
Do you have any concerns regarding chiropractic treatment:
MEDICAL HISTORY
Who is your primary medical doctor:
Date of last visit:Date of last physical exam:
Is there any chance that you are currently pregnant (Circle One) Yes / NoIf yes, how many weeks:
Have you had x-rays taken in the last 6 months (Circle One) Yes / NoIf yes, what body part:
Please list all previous surgeries: ______
Height:______Weight: ______
Are you currently diagnosed with any illnesses and/or other health conditions?
Please list any medications that you are currently taking (Please include regularly used over the counter medications):
Please list any allergies that you have had:
Please list any conditions that your family has been diagnosed with and who (Father, Mother, Brother, Grandparents):
Please list any repetitive movements, positions, and/or activities you do on a daily basis: ______
Patient Signature: ______Date:
Guardian or Spouse Signature: ______Date: