New Patient Form

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Date:
Name:
Date of Birth:
Address:
E-mail:
Cell Phone:
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Home Phone:
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Age:
Marital Status:
Social Security Number:
Occupation:
Employer:
Work Phone:
-
Employers Address:
Spouse:
Spouse Occupation:
Spouse Employer:
Emergency Contact Phone #:
-
How did you find out about our office?
Family Medical Doctor:
Please check any and all insurance coverage that may apply:
Permission to contact your medical doctor if needed?
Name of Primary Insurance Company
Policy Holder:
Policy Holder DOB
Relationship to Patient:
Policy Holder's SS Number:
Name of Secondary Insurance Company (if any):
Chief Complaint: Purpose of this appointment:
Date symptoms appeared or accident happened:
Is this due to:
Does your condition seem to be:
Check all locations where you feel pain: :
How often do you experience your symptoms?
Are your symptoms worse in the:
Does your condition affect:
What best describes your symptoms:
Aggravating factors:
Relieving Factors:
At its worse, please rate your pain at its worse: 0 being no pain — 10 being unbearable
How much has your pain interfered with your daily activities?
How much has your pain interfered with your social activities?
Who have you seen for your symptoms?
What treatment did you receive?
When did you receive this treatment?
Have you had any test performed for your symptoms?
When were these test performed?
Have you had similar symptoms in the past?
Tobacco use:
Alcohol use:
If yes to tobacco or alcohol, how often?
Women: Is there a chance you are pregnant?
Please list previous surgeries:
Please list current medications:
Please list all known allergies:

FAMILY HISTORY: Please review the below-listed diseases and conditions and if applicable, circle any family member who has the condition.

REVIEW OF SYSTEMS
For new patients, established patients who may be having a new problem, or our patients who we haven't seen for a while, we need to update our records as to your general medical health. In each area, if you are not having any difficulties, please check "No Problems." If you are experiencing any of the symptoms listed, PLEASE CIRCLE THE ONES THAT APPLY, or explain any that may not be listed. If you have any questions about this, please ask one of the technicians, or your doctor.

Health in General:
Ear, Nose, Mouth and Throat:
C-V (Heart & Blood Vessels):
Resp. (Lungs & Breathing)
GI (Stomach & Intestines):
GU (Kidney & Bladder):
MS (Muscles, Bones, Joints):
Integ. (Skin, Hair & Breast):
Neurologic (Brain & Nerves):
Psychiatric (Mood & Thinking):
Endocrinologic (Glands):
Hematologic (Blood/Lymph):
Allergic/Immunologic:

Family History

Arthritis
Back Trouble
Cancer
Diabetes
Heart Trouble
High Blood Pressure
Migraine
Scoliosis

I certify the information provided is accurate to the best of my knowledge.

Signature of Patient/Legal Guardian and Date:  Required upon arrival of initial visit.

AUTHORIZATION AND RELEASE: I authorize payment of insurance benefits directly to the chiropractor or chiropractic office. I authorize the doctor to release all information necessary to communicate with personal physicians and other healthcare providers and payers and to secure the payment of benefits. I understand that I am responsible for all costs of chiropractic care, regardless of insurance coverage. I also understand that if I suspend or terminate my schedule of care as determined by my treating doctor, any fees for professional service will be immediately due and payable. Add initials to box *
The patient understands and agrees to allow this chiropractic office to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations, and coordination of care.  We want you to know how your PHI is going to be used in this office and your rights concerning those records.  If you would like to have a more detailed account of our policies and procedures concerning the privacy of our PHI we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent.  The following person(s) have my permission to receive my personal health information: Add initials to box.*
The following person(s) have my permission to receive my personal health information. List names in box below. Type N/A in box if you do not wish for anyone to see your records. *
Patient or guardian signature and date: (in office only): _______________________________________date________________ (please type initials in box)*
Guardian's Signature Authorizing Care_________________________ Date:______________ (please type initials in box) *