New Patient Health Record

Click Icon to Print

Please be aware that this a print only form! After filling out please hit the print button located below and or your print button located under file in your browser window. Your information will not be sent via the internet to our office or any other location. Please print and bring into the office. Thank You.

Confidential Patient Health Record			Date:
			I.D. #

Personal History

Name:

Address:

City:

State:

Zip/Postal Code:

Home Phone:

Birth Date: Age: Sex: M F

Social Security#:

Driver's License #:

Primary Insurance ID#:

Fill In One: Married Single Widowed Divorced Separated

Business Employer:

Type of Work:

Business Phone:

Spouse's Social Security #:

Name of Spouse:

Spouse's Social Insurance #:

Spouse's Employer:

Business Phone:

Type of Work:

Name and Ages of Children:

Referred by:

Emergency Contact Information:

Name: Number: Relationship:

Who is responsible for your bill? You and Spouse Workers' Comp Auto Ins. Medicare Medicaid Personal Health Ins.

Personal Health Ins:

Health Card #:

Insured Person's Name:

Date of Birth

:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::

Current Health Condition

Unwanted Health Condition:

Other Doctors Seen For Condition: Yes No

Who?

Type of Treatment:

Results:

When Did This Condition Begin?

Has This Condition Occurred Before? Yes No

Is Condition: Job Related Auto Accident Home Injury Fall Other

Date of Accident:

Time of Accident:

Have Your Made A Report of Your Accident to Your Employer: Yes No

Drugs You Now Take: Nerve Pills Pain Killers/Muscle Relaxers Blood Pressure Medicine

Insulin Other:

Do You Wear a Shoe Lift? Yes No

Do You Suffer From Any Condition Other Than That Which You Are Now Consulting Us?

Past Health History

Major Surgery/Operations: Appendectomy Tonsillectomy Gall Bladder Hernia Back Surgery

Broken Bone Other:

Major Accidents or Falls:

Hospitalization (Other Than Above):

Previous Chiropractic Care: None Doctor's Name & Approximate Date or Last Visit

Below are a list of diseases which may seem unrelated to the purpose of your appointment. However, these questions must be answered carefully as these problems can affect your overall course of care.

Check Any Of the Following Diseases You Have Had:

Pneumonia	Mumps	Influenza	INTAKE
Rheumatic Fever	Small Pox	Pleurisy	Coffee
Polio	Chicken Pox	Arthritis	Tea
Tuberculosis	Diabetes	Epilepsy	Alcohol
Whooping Cough	Cancer	Mental Disorders	Cigarettes
Anemia	Heart Disease	Lumbago	White Sugar
Measles	Thyroid	Eczema

Have you been tested HIV positive? Yes No

Check Any Of The Following You Have Had The Past 6 Months:

Musculo-Skeletal Code			Genito-Urinary Code		Females Only:
	Low Back Pain	Difficult Chewing/Clicking Jaw		Bladder Trouble	Date of Last Period?
	Pain Between Shoulders	General Stiffness		Painful/Excessive Urination
	Neck Pain	Gas/Bloating After Meals		Discolored Urine	Are you pregnant?
	Arm Pain	Heartburn			Yes No Not Sure
	Joint Pain/Stiffness	Black/Bloody Stool
	Walking Problems	Colitis

Nervous System Code			C-V-R Code
	Nervous	Fainting		Chest Pain
	Numbness	Convulsions		Short Breath	Varicose Veins
	Paralysis	Cold/Tingling Extremities		Blood Pressure Problems	Ankle Swelling
	Dizziness	Stress		Irregular Heartbeat	Stroke
	Forgetfulness			Heart Problems
	Confusion/Depression			Lung Problems/Congestion

General Code		EENT Code		Gastro-Intestinal Code
	Fatigue		Vision Problems		Poor/Excessive Appetite	Hemorrhoids
	Allergies		Dental Problems		Excessive Thirst	Liver Problems
	Loss of Sleep		Sore Throat		Frequent Nausea	Gall Bladder Problems
	Fever		Ear Aches		Vomiting	Weight Trouble
	Headaches		Hearing Difficulty		Diarrhea	Abdominal Cramps
	Asthma		Stuffed Nose		Constipation

Male/Female Code		Family History
	Menstrual Irregularity	The following members have a same or similar problem as I do:
	Menstrual Cramps		Mother	Child
	Vaginal Pain/Infection		Father
	Breast Pain/Lumps		Brother
	Prostate/Sexual Dysfunction		Sister
	Other Problems		Spouse

Analysis:

Diagnosis:

Patient Accepted: Yes No Referred

Doctor's Signature

Most patients that come to our office have one of two objectives in mind concerning their health care. Some patients come for symptomatic relief of pain or discomfort (Relief Care). Others are interested in having the cause of the problem as well as the symptoms corrected and relieved (Corrective Care). Your Doctor will weigh your needs and desires when recommending your treatment program.

Please Check the type of care desired so that we may be guided by your wishes whenever possible.

Relief Care

Corrective Care

Check here if you want the Doctor to select the type of care appropriate for your condition

Date:

Patient's Signature:____________________________________________________________

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that the Doctor's Office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to the Doctor's Office will be credited to my account on receipt. However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate, any fees for professional services rendered me will be immediately due and payable.

I hereby authorize the Doctor to treat my condition as he and she deems appropriate. It is understood and agreed the amount paid the Doctor, for x-rays, is for examination only and the X-ray negatives will remain the property of this office, being on file where they my be seen at any time while a patient of this office. The patient also agrees that he/she is responsible for all bills incurred at this office.

Patient's Signature:_________________________________________________ Date:______________

Consent to Treat a Minor_____________________________________________ Date:______________

Guardian or Spouse's
Signature of Authorizing Care_________________________________________ Date:______________

Click Icon to Print