Short Chiropractic Inc
WELCOMES YOU TO OUR OFFICE
CONFIDENTIAL HEALTH INFORMATION QUESTIONNAIRE
PLEASE READ AND COMPLETE EACH FORM
This information is needed so we can better serve you. Please fill in ALL portionsof the form. If you need assistance, please ask our receptionist, and we will behappy to have our Patient Services Representative help you.
Your Name:______Date:______ACCT#:______
Address: ______
City:______State:______Zip:______
Home Phone #: ______Cell Ph: ______SEX: M F HEIGHT:___WEIGHT____
Age:____ Date of Birth: ______SS#: ______E-mail: ______
Marital Status: MarriedSingleDivorceWidowed Drivers License # ______
Your Occupation: ______Employed by:______
Phone #:______Address: ______
Student:Full-Time_____Part-Time_____Name of School:______
Your Spouse’s Name:______Spouse date of birth:______
Spouse’s Employer: ______Spouse’s work phone #: ______
Name of person to contact in case of emergency:______
Their home and work phone number:______
Name of nearest relative not living with you:______
Their phone number:______
Who referred you to this office so we may thank them? ______
Referring Physician: ______
Is your visit due to an accident? ? Yes / ? No___AUTO___WORK (DATE:______)
Have you had chiropractic in the past? ______If yes, When? ______
Doctor’s Name: ______Results:______
Who is Your Medical Doctor? ______Last Visit: ______
Please complete the information on the opposite side. Thank you!
Insurance Coverage Information Page 2
Primary Insurance:
Insurance Carrier: ______Phone: ______
Policy Holder name: ______Policy Number: ______
Group Number:______Relationship: ___Spouse ___Child ___Other
Insured Date of Birth:______Insured Home Phone:______Insured Work ______
Secondary Insurance:
Insurance Carrier: ______Phone:______
Policy Holder name: ______Policy Number: ______
Group Number: ______Relationship: Spouse Child Other
Insured Date of Birth:______Insured Home Phone:______Insured Work______
Auto / Personal Injury:
Do you have “Med Pay” on your Auto Policy: Yes / No Amount: $ ______
Insurance Carrier Name: ______Phone:______
Adjuster: ______Claim Number: ______
TREATMENT OF MINOR (must be signed by parent or legal guardianif patient is a minor under age 18): I hereby authorize Short Chiropractic Inc. and its assistants to administer chiropractic care as deemed necessary to my ______. (Relationship)
______
SIGNATURE OF PARENT/GUARDIAN DATE
DESCRIBE MAJOR COMPLAINTS & SYMPTOMS:
______
Where is your pain? How does it feel? Draw your pain using the following key.BACK VIEW FRONT VIEW
Please complete the information on the next page. Thank you!
Page 3
List any doctors or therapists that you have seen for this complaint:
- ______Specialty______
- ______Specialty______
3. ______Specialty______
List any operations that you’ve had and approximate dates:
1. ______Date: ______Dr: ______
2. ______Date: ______Dr: ______
3. ______Date: ______Dr: ______
Are you allergic to any medication? ____ Please list: ______
______
Are you taking any medications? _____Please list: ______
______
Do you wear Orthotics (shoe inserts)? ? Yes / ? No If yes, what type? ______
Please check the appropriate box for any of the following symptoms which you currently have.
GENERAL GASTRO-INTESTINAL CARDIO-VASCULAR SKIN
Allergies Colon Trouble Hardening of arteries Bruise
Convulsions Constipation High blood pressure Dryness
Dizziness or Fainting Diarrhea Low blood pressure Skin eruptions (rash)
Headache Difficult digestion Pain over heart Varicose veins
Neuralgia Distension of abdomen Poor circulation
Numbness/sensation loss Gallbladder Trouble Rapid heartbeat FOR WOMEN ONLY
Hemorrhoids Slow heartbeat Congested breasts
MUSCLE & JOINT Liver trouble Swelling of ankles Cramps or backache
Arthritis Pain of stomach Slurred speech Hot flashes
Bursitis Difficult swallowing Weakness/Clumsiness Irregular cycle
Foot Trouble Lumps in breast
Lowback pain EYES,EARS,NOSE,&THROAT RESPIRATORY Menopausal symptoms
Neckpain or stiffness Asthma Chest pain Painful menstruation
Pain between shoulders Colds Chronic Cough Vaginal Discharge
Sciatica Hearing loss Difficult breathing Pregnant yes no
Swollen Joints Earache Spitting up blood Date of Last Period______
Pain, numbness/ cramps Ear Discharge Spitting up phlegm Previous Miscarriages? yes no
Shoulders Ear noises Wheezing
Arms Eye pain
Elbows Nasal obstruction GENITO-URINARY
Hands Nosebleeds Bed-wetting
Hips Sinus infection Blood in urine
Legs Blurred vision Frequent urination
Knees Loss of vision Inability to control kidneys
Feet Kidney infection or stones
Painful irritation
Prostate trouble
Pus in urine
Alcohol Drugs
Coffee Soft Drinks
Tobacco Exercise
Page 4
Relevant medical history: (Please circle the conditions you have or had previously)
Aids/HIV Diabetes Heart problems Rheumatic Fever
Alcoholism Digestion problems Hepatitis Scarlet Fever
Arthritis Dizziness High blood pressure Sciatica
Asthma Eczema Measles Scoliosis
Anemia Emphysema Multiple Sclerosis Sinus trouble
Appendicitis Epilepsy Mumps Stroke
Arteriosclerosis Fibromyalgia Muscular DystrophyTuberculosis
Back pain or spasm Foot Problems Neck pain or spasms Typhoid Fever
Cancer Goiter Numbness Ulcers
Chicken Pox Gout Pacemaker Venereal disease
Concussion Hand or wrist pain Pneumonia
ConvulsionHeadaches Polio
Does anyone in your family have a similar health related problem? ? Yes / ? No
Who: ______What condition:______
I attest that the above information is true and correct to the best of my knowledge. I further understand that any charges incurred by me in this office are my sole responsibility, despite any insurance plan, legal involvement, or settlement. I hereby authorize and direct my medical benefits to be paid to Short Chiropractic Inc and agree that I am financially responsible for non-covered services or items. I hereby give permission to Short Chiropractic Inc to administer treatment and perform such general procedures as the doctor may deem necessary in the diagnosis and/or treatment for my condition.
Patient’s Signature: ______Date______
Parent or Guardian: ______
Signature: ______Date ______