Please complete this form to the best of your ability.
Personal History (Required fields - *)
		Date	*
Please complete this form to the best of your ability. If you need help our receptionist will be glad to assist you!
Full Name	*	Address	*
City	*	State	*
		Zip	*
Phone(Home)	*	Phone(Work)	*
		Cell	*
Email	*	Sex	M  F* Single Seperated Married Widowed Divorced *
Birth	*	Social Security#	*
Do you like appointment reminder calls? No Cell Home
How did you hear about our office? TV Phonebook Newspaper Billboard Website Family/Friend *
		Other
Occupation	Employed Student Other	Emergency Contact	*
		Phone	*
Spouse’s Name		Date Of Birth
		Social Security#

Accident Injury and Insurance Information
Could your present problems be due to an accident-injury?		Date
Type of accident-injury: Auto On-the-Job Slip/Fall Personal Other
We do not accept assignment on work related injuries.
Name of Attorney handling your case		Phone
Type of Insurance you plan to use to help pay your account: Auto Health Medicare Self-Pay Other
Insurance company		Phone
Insured’s Name		Insured’s DOB

Your Injury, Illness, or Condition
What is your injury, illness or condition	*
Previous interventions, treatments, medications, surgery, or care you’ve sought for your injuries	*
Do you suffer from any condition other than that which you are now consulting us?	*
Have you had previous Chiropractic care? Yes No
Condition treated
Month/Year of last visit

Health History / Trauma	P- Previous, N- New
P    N    Low Back Pain	P    N    Fractured Bones
P    N    Spinal Taps	P    N    Fainting
P    N    Arm Pain	P    N    Dislocation
P    N    Scoliosis	P    N    Birth Defects
P    N    Headaches	P    N    Joint Replacement
P    N    Diabetes	P    N    Osteoporosis
P    N    Neck Pain	P    N    Metal Screws/implants
P    N    High Blood Pressure	P    N    Cancer
P    N    Pain Between Shoulders	P    N    Cervical Whiplash
P    N    Stroke	P    N    Tumor
P    N    Leg Pain	P    N    Electronic Implant
P    N    Aneurysm	P    N    Cyst
P    N    Cold/Tingling Fingers or Toes	P    N    Pacemaker
P    N    Convulsions	P    N    Ear Infections
P    N    Numbness	P    N    Ruptured Spinal Disc
P    N    Seizures	P    N    Birth Complications
P    N    Allergies	P    N    Slipped spinal disc
P    N    Memory Lapse	P    N    Asthma
P    N    Loss of Sleep	P    N    Pinched Nerve
P    N    Dizziness	P    N    Bed Wetting
P    N    Stomach/Digestive Problems	P    N    Spinal Surgery
P    N    Concussion	P    N    Heart Disease
P    N    Walking problems	P    N    Spinal Infections
P    N    Knocked Unconscious	P    N    Fever

Are you Pregnant? Yes No	Other serious illness
	Previous injuries or trauma not listed above

Prior Surgeries
Date		Type
Date		Type
Date		Type

Current Medications
Name	Reason for taking
Name	Reason for taking
Name	Reason for taking

Social and Occupational History
Job description	*
Recreational Activities
Lifestyle (hobbies, level of exercise, alcohol, tobacco and drug use, diet)

Family Health History
Associated health problems of relatives

Treatment Authorization
Today you’ll receive a free initial consultation with the doctor. If further tests are needed such as exams or x-rays, the necessity and cost will be explained before they are performed. You’ll be happy to know that these tests are covered by most insurances. I hereby authorize this office and its staff and doctors to examine and treat my condition as the doctors deem appropriate. I grant authority for these procedures to be performed. I clearly understand and agree that all services rendered me are charged directly to me and that I am responsible for payment of services by this office. Should collection of past due amount become necessary, I will become responsible for all charges, fees and attorney fees. I (we) hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize the use of this signature on all insurance submissions.
Patient’s signature (x) *	Date	*
	Entered By
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