Dr. Williams Chiropractic Office
(909) 592-2823 – Office (909) 394-7825 - Facsimile
INITIAL OFFICE PAPERWORK
PLEASE PRINT
Dr. Williams Chiropractic Office
(909) 592-2823 – Office (909) 394-7825 - Facsimile
______First Name M.I. Last Name
______
Street AddressApartment Number
______
CityStateZip Code
______
(Area Code) Home Phone Number(Area Code) Alternate Phone NumberExtension
______
(Area Code) Fax NumberE-Mail Address
______-______-______/______/______Single______Divorced______
Social Security Number Date of Birth
Married ______Spouse’s Name ______Children: Yes______No______
TYPE OF INJURY
Personal______Motor Vehicle ______Sports ______Work Related ______
Please Mark Area(s) & Type of Pain On The Drawings Using The Codes Listed Below
Dr. Williams Chiropractic Office
(909) 592-2823 – Office (909) 394-7825 - Facsimile
A-Ache N-Numbness P-Pain S-Soreness ST–Stiffness T-Tingling
Dr. Williams Chiropractic Office
(909) 592-2823 – Office (909) 394-7825 - Facsimile
Dr. Williams Chiropractic Office
(909) 592-2823 – Office (909) 394-7825 - Facsimile
(Page 1 of 3)
Dr. Williams Chiropractic Office
(909) 592-2823 – Office (909) 394-7825 - Facsimile
PLEASE LIST THE REASON(S) YOU WOULD LIKE TO BE TREATED BY THIS OFFICE
Dr. Williams Chiropractic Office
(909) 592-2823 – Office (909) 394-7825 - Facsimile
1)______
Dr. Williams Chiropractic Office
(909) 592-2823 – Office (909) 394-7825 - Facsimile
How Long Have You Had This Condition?Day(s)Week(s)Month(s)Year(s)
Dr. Williams Chiropractic Office
(909) 592-2823 – Office (909) 394-7825 - Facsimile
2) ______
How Long Have You Had This Condition?Day(s)Week(s)Month(s)Year(s)
Dr. Williams Chiropractic Office
(909) 592-2823 – Office (909) 394-7825 - Facsimile
Dr. Williams Chiropractic Office
(909) 592-2823 – Office (909) 394-7825 - Facsimile
Have You Had Any Spinal Surgical Procedures Such As Disc And/Or Vertebrae Fusions? Yes ______No______If Yes When, Where, And Why? ______
Have You Had Any Surgical Procedures On Your Shoulder(s), Arms, Forearms, Wrist, Hands, Hip(s), Thighs, LegsAnd/Or Feet? Yes _____ No_____ If Yes When, Where, And Why? ______
______
Dr. Williams Chiropractic Office
(909) 592-2823 – Office (909) 394-7825 - Facsimile
Dr. Williams Chiropractic Office
(909) 592-2823 – Office (909) 394-7825 - Facsimile
Have You Had Any Surgical Procedures Such As Brain, Heart, Liver, Lungs...etc? Yes ______No ______If Yes When, Where, And Why? ______
______
In order for this office to properly serve you, and help your condition, we need to know which of the following chiropractic treatment plans do you desire.
Acute Care aka Aspirin Care______
I just want the pain to go away.
Dr. Williams Chiropractic Office
(909) 592-2823 – Office (909) 394-7825 - Facsimile
Rehabilitative Care aka Current Condition Care______
I want the pain to go away and to correct the problem.
Dr. Williams Chiropractic Office
(909) 592-2823 – Office (909) 394-7825 - Facsimile
Preventative Care aka Wellness Care______
I want to have regular chiropractic and spinal care.
PATIENT NOTES:
______
Dr. Williams Chiropractic Office Financial Policy
Dr. Williams Chiropractic Office
(909) 592-2823 – Office (909) 394-7825 - Facsimile
X-RAY'S, BRACES, ORTHOPEDIC SUPPORTS, SUPPLEMENTS, & VITAMINS are paid for as they are rendered!
Dr. Williams Chiropractic Office
(909) 592-2823 – Office (909) 394-7825 - Facsimile
I understand that as a courtesy to me, the patient, Dr. Williams Chiropractic Office will bill my insurance company for me for all allowable benefits however, this office does not have a contract with my insurance company therefore I, the patient, am responsible for all chiropractic services rendered to me. Payment is expected as chiropractic services are rendered!
Date ______/______/______Signature ______
(Page 2 of 3)
PLEASE CHECK ALL PRESENT SYMPTOMS
(Please Circle Right or Left)
DATE _____/_____/______NAME ______
PRINT FIRST PRINT MIDDLE PRINT LAST
HEAD NECK SHOULDERS
_____ HEADACHES _____ PAIN IN NECK _____ PAIN IN RIGHT SHOULDER
_____ SINUS _____ NECK PAIN WITH MOVEMENT _____ PAIN IN LEFT SHOULDER
_____ MIGRAINE HEADACHE _____ MUSCLE SPASMS _____ PAIN ACROSS SHOULDERS
_____ HEADACHE ON TOP OF HEAD _____ UNABLE TO MOVE SHOULDER
_____ HEADACHE ON BACK OF HEAD _____ MUSCLE SPASMS IN SHOULDER
_____ HEADACHE ON FOREHEAD
_____ HEADACHE ON SIDE OF HEAD ARMS & HANDS MID - BACK
_____ HEAD FEELS HEAVY _____ PAIN IN UPPER RIGHT OR LEFT ARM _____ MID BACK PAIN
_____ LIGHT HEADEDNESS _____ PAIN IN RIGHT OR LEFT ELBOW _____ DULL PAIN
_____ DIZZINESS _____ PAIN IN RIGHT OR LEFT FOREARM _____ SHARP PAIN
_____ RINGING IN EARS _____ PAIN IN RIGHT OR LEFT HAND
_____ NUMBNESS IN RIGHT OR LEFT EXTREMITY
ABDOMEN LOWER BACK CHEST
_____ STOMACH PAIN _____ LOW BACK PAIN _____ CHEST PAIN
_____ GAS _____ LOW BACK PAIN UPON MOVEMENT _____ RADIATING CHEST PAIN
_____ CONSTIPATION _____ MUSCLE SPASMS _____ SHORTNESS OF BREATH
_____ DIARRHEA _____ BREAST PAIN RIGHT OR LEFT
_____ NAUSEA LEGS & FEET
_____ HEMORRHOIDS _____ PAIN IN UPPER RIGHT OR LEFT LEG
_____ PAIN IN RIGHT OR LEFT KNEE
_____ PAIN IN RIGHT OR LEFT LEG
_____ PAIN IN RIGHT OR LEFT ANKLE
_____ PAIN IN RIGHT OR LEFT FOOT
NOTES
______
(Page 3 of 3)