Revision 10.29.

2009

Phone Number:

Patient Information
Date: First Name: Sex: Marital Status: Home #: Address: City: Emergency Contact: Email: State: Emergency Relation: Zip: Emergency Phone: M Yes F No SSN: Middle Name: Height: Spouse Name: Cell #: Birthday: Last Name: Weight: # of Children: Work #:

Referral Information
Referring Physician: Advertisement: Referred Directory: Yes Yes No No Referred Patient: Advertisement: Referred Directory: Referred by:

Employer Information
Employed: Employer Address: Employer City: Occupation: Work Duties: Employer State: Work Supervisor: Employer Zip: Supervisor #: Full Time Part Time Homemaker Unemployed Employer Name:

Insurance Information
Payment: Personal 3rd Party Self Resp. for Payment: Primary Phone #: Responsible Phone : Primary ID/Policy: Payment Name: Payment Address: Payment City: Primary Group #: Secondary Name: Secondary Address: Secondary City: Secondary Group #: Claim #: Attorney Name: Secondary State: Secondary Name: Claim Contact: Attorney Phone #: Secondary Zip: Secondary DOB: Claim Phone #: Payment State: Primary Name: Secondary Phone #: Payment Zip: Primary DOB: Secondary ID/Policy:

Complaint Information
Injury Occurred: Injury Origin: Desc Discomfort: Frequency: Interfere w/ Activities: Missed Work: Affected Appetite: Reduced Work: Does it Worsen: Weather Affects it: Aggravates Condition: Improves Condition: Received Treatment: X-rays Taken: Same Condition Before: Yes Yes Yes No No No Explain: Explain: Date: Practitioner: Always Yes Yes Yes Yes Yes Yes No No No No No No Explain: Explain: Explain: Explain: Hourly Daily Affected Sleep: Unable to Work from: Yes Occasionally No Unable to Work til: Automobile Work Third-Party Other Injury Date:

History
Last Physical Exam: Phys City: Health Conditions: Previous Chiro Care: Chance Pregnant: Medications: Supplements: Broken Bones: Sprains/Strains: Hospitalized: Surgery: Auto Accident: Struck Unconscious: Eating Disorder: Stroke: Family Health Hist: Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No Treatment: Treatment: Explain: Explain: Treatment: Treatment: Explain: Explain: Yes Yes No No Explain: Explain: Yes Yes No No Explain: Explain: Yes Yes No No Date: Planning: Yes No Explain: Primary Phys: Phys State: Phys Phone #: Phys Zip:

Patient Social
Alcohol: Diet Food Products: OTC Stimulants: Homemade Food: Soft Drinks: Water: Daily Daily Daily Daily Daily Daily Weekly Weekly Weekly Weekly Weekly Weekly Occasion Occasion Occasion Occasion Occasion Occasion Never Never Never Never Never Never Caffeine: Drugs: Exercise: Processed Food: Tobacco: Daily Daily Daily Daily Daily Weekly Weekly Weekly Weekly Weekly Occasion Occasion Occasion Occasion Occasion Never Never Never Never Never

Health Checklist
Allergies Arteriosclerosis Back Pain Bruise Easily Cold Extremities Depression Dizziness Fatigue Hemorrhoids Irregular Heart Beat Kidney Stones Loss of Smell Pacemaker Prostate Trouble High Blood Pressure Spinal Curvatures Swollen Joints Ulcers Other: Alcoholism Arthritis Breast Lump Cancer Constipation Diabetes Excessive Menstruation Frequent Urination High Blood Pressure Irregular Menstrual Cycle Loss of Memory Loss of Taste Polio Sciatica Sinus Infection Stroke Thyroid Condition Varicose Veins Anemia Asthma Bronchitis Chest Pain Cramps Digestion Problems Eye Pain or Difficulties Headache Hot Flashes Kidney Infection Loss of Balance Nosebleeds Poor Posture Shortness of Breath Insomnia Swelling of Ankles Tuberculosis Venereal Disease

Patient Signature:

Date: