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Patient Information

First Name *:
Middle Initial:
Last Name:
Gender:
MaleFemale
Date of Birth (mm/dd/yyyy):
Home Phone Number:
Cell Phone Number:
Work Phone Number:
Street Address:
City:
State:
Zipcode:
Email Address *
Married/Civil Union:
How did you find out about our office?:

Emergency Contact

Emergency Contact Full Name:
Relationship:
Emergency Contact Phone Number:

Employment Information

Employment:
Employer Name:
Employer Address:
Occupation:

About Patient

What is the purpose of your visit?:
Current Symptoms:
Where did the injury occur?:
Date of Injury (if known):
Please Describe how the injury, pain, or discomfort originated:
Please describe your pain/discomfort:
Rate from 1 - 10 (10 being worst):
Select frequency you experience pain from this condition:
AlwaysHourlyDailyOccasionally
Does this condition interfere with any of your daily activities or routines?:
NoYes
Has this condition affected your quality of sleep or ability to sleep?:
NoYes
Has this condition affected your appetite?:
NoYes
If Yes, Explain:
Have you missed any work due to this injury?:
NoYes
If Yes, what dates have you missed work because of this?:
Have you reduced or limited your work hours because of this condition?:
NoYes
If Yes, Explain:
Is the pain/discomfort worse at certain times of the day?:
NoYes
If Yes, Explain:
Does the weather affect your pain/discomfort?:
NoYes
If Yes, Explain:
List anything that aggravates your condition:
List anything that relieves or improves your condition:
Have you received professional treatment for this condition?:
NoYes
If Yes, Explain:
Have you had X-rays taken for this condition?:
NoYes
If Yes, Where?:
Have you ever had this same condition?:
NoYes
If Yes, When?:
List other practitioners seen for this injury/condition:

Please select all that you have had or currently have.

AllergiesAlcoholismAnemiaArteriosclerosisArthritisAsthmaBack PainBreast LumpBronchitisBruise EasilyCancerChest PainCold ExtremitiesConstipationCrampsDepressionDiabetesDigestion Problems DizzinessExcessive MenstruationEye Pain or DifficultiesFatigueFrequent UrinationHeadacheHemorrhoidsHigh Blood PressureHot FlashesIrregular Heart BeatIrregular Menstrual CycleKidney InfectionKidney StonesLoss of MemoryLoss of BalanceLoss of SmellLoss of TasteNosebleeds PacemakerPolioPoor PostureProstate TroubleSciaticaShortness of BreathSinus InfectionSleep Problems/InsomniaSpinal CurvaturesStrokeSwelling of AnklesSwollen JointsThyroid ConditionTuberculosisUlcersVaricose VeinsVenereal DiseaseOther

Social History & Life Choices

Alcohol:
Caffeine Drinks & Products:
Diet Food Products:
Medications:
Energy Products or Over-the-Counter Stimulants:
Exercise:
Fresh & Homemade Foods:
Preprocessed, Packaged, & Restaurant Food:
Soft Drinks:
Tobacco:
Water:

For Women Only

Are you pregnant?:
NoYes
Are you nursing?:
NoYes
Are you taking birth control?:
NoYes
Do you experience painful periods?:
NoYes
Do you have irregular cycles?:
NoYes
Do you have breast implants?:
NoYes

Personal Incident History

Broken bones?:
NoYes
If yes, briefly explain:
Been hospitalized?:
NoYes
If yes, briefly explain:
Past surgeries?:
NoYes
If yes, briefly explain:

Stroke?:
NoYes
If yes, briefly explain:
Struck unconscious?:
NoYes
If yes, briefly explain:
Major sprain/strains?:
NoYes
If yes, briefly explain:

Family Health History

Please list diagnosed health conditions and untimely deaths.(condition, relationship to you)
(Family members include: Parents and siblings and maternal and paternal grandparents/aunts/uncles)

(Example: arthritis, cancer, diabetes, heart disease, kidney disease, high cholesterol, etc.)

I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.

* I agree with this statement of authorization

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