Chiropractic Registration and HisteryPatient Information InsuranceDffie _

SS/HIC/Patient 10 # _

Patient Name,__~~_,_,__-----------------------------------Last Name

First Name Middle Initial

Address _

Ci~ _

8tate _ Zip _

E-mail _

Sex 0 M 0 F Age _

Birthdate _

o Married 0Widowed o Single o Minor

o Separated

Occupation _

Patient Employer/School _

o Divorced o Partnered for years

Employer/School Address _

Employer/School Phone ( ), _

Spouse's Name _

Birthdate _

SS# _

Spouse's Employer _

Whom may we thank for referring you? _

Phone NumbersHome Phone ( ) _ Cell Phone (__ ) _

Best time and place to reach you _

IN CASE OF EMERGENCY, CONTACT

Name _ Relationship _

Home Phone ( ) _ Work Phone ( ) _

Patient Condition

Who is responsible for this account? =--;;~ __::.;....__',

Relationship to Patient ---;. _

Insurance Co. -------------------------------------is--~~~-

Group# ~~~----~---

Is patient covered by additional insurance? 0 Yes 0 No

Subscriber's Name =::-- _

Birthdate _ SS#~~-L----------

Relationship to Patient -+- _Insurance Co. --....:"""'--+ _

Group# T3~~-----------

ASSIGNMENT AND RELEASEI certify that I, and/or my dependent(s). have insurance coverage with

---------c-;-----,-;-.,--.,----, __----,,--,-------.c--- and assign directly toName of Insurance Company(ies)

Dr. I" all in urance benefits. ifany. otherwise payable to me for services rendered. I understand that I am financiallyresponsible for all charges whether or not paid by insurance. I authorize the use ofmy signature on all insurance submissions.

The above-named doctor may use my health care information and may disclosesuch information to the above-named Insurance Company(ies) and their agents forthe purpose of obtaining payment for services and determining insurance benefits orthe benefits payable for related services. This consent will end when ,my currenttreatment plan is completed or one year from the date signed below.

Date

~(cident InformationIs condition due to an accident? 0 Yes 0 No Date -".--=---"=,..2:

Type of accident 0 Auto 0Work 0Home 0Other

To whom have you made a report of your accident?o Auto Insurance 0 Employer 0Worker Camp. 0Other

Attorney Name (if applicable) _

Reason for Visit _

When did your symptoms appear? _

Is this condition getting progressively worse? 0Yes 0 No 0 Unknown

Mark an X on the picture where you continue to have pain, numbness, or tingling.

Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain) _

Type of pain: 0 Sharp 0 Dull 0 Throbbing 0 Numbnesso Burning 0 Tingling 0 Cramps 0 Stiffnesso Achingo Swelling

o Shootingo Other

How often do you have this pain? _

Is it constant or does it come and go? _

Does it interfere with your 0 Work 0 Sleep 0 Daily Routine 0 Recreation

Activities or movements that are painful to perform 0 Sitting 0 Standing 0Walking 0 Bending 0 Lying Down

(Vers.C2SSS04) - 0 V E R - #20648 - © 2004 Medical Arts Press· 1-800-328-2179

Health HistoryWhat treatment have you already received for your condition? D Medications D Surgery D Physical Therapy

D Chiropractic Services D None D Other

Name and address of other doctor(s) who have treated you for your condition

Date of Last: Physical Exam Spinal X-Ray Blood Test

Spinal Exam Chest X-Ray Urine Test

Dental X-Ray MRI, CT-Scan,Bone Scan

Place a mark on "Yes"or "No" to indicate if you have had any of the following:

AIDS/HIV DYes DNo Chicken Pox DYes DNo Liver Disease DYes DNo RheumatoidArthritis DYes DNo

Alcoholism DYes DNo Diabetes DYes DNo Measles DYes DNo Rheumatic Fever DYes DNo

Allergy Shots DYes DNo Emphysema DYes DNo MigraineHeadaches DYes DNo Scarlet Fever. DYes DNo

Anemia DYes DNo Epilepsy DYes DNo Miscarriage DYes DNo Stroke DYes DNo

Anorexia DYes DNo Fractures DYes DNo Mononucleosis DYes DNo Suicide Attempt DYes DNo

Appendicitis DYes DNo Glaucoma DYes DNo Multiple Sclerosis DYes DNo Thyroid Probler1l.s DYes DNo

Arthritis DYes DNo Goiter DYes DNo Mumps DYes DNo Tonsillitis DYes DNo

Asthma DYes DNo Gonorrhea DYes DNo Osteoporosis DYes DNo Tuberculosis DYes DNo

Bleeding Disorders DYes DNo Gout DYes DNo Pacemaker DYes DNo Tumors, Growths DYes DNo

Breast Lump DYes DNo Heart Disease DYes DNo Parkinson'sDisease DYes DNo Typhoid Fever DYes DNo

Bronchitis DYes DNo Hepatitis DYes DNo Pinched Nerve DYes DNo Ulcers DYes DNo

Bulimia DYes DNo Hernia DYes DNo Pneumonia DYes DNo Vaginal Infections DYes DNo

Cancer DYes DNo Herniated Disk DYes DNo Polio DYes DNo Venereal Oisea~e DYes DNo

Cataracts DYes DNo Herpes DYes DNo Prostate Problem DYes DNo Whooping Cough DYes DNo

Chemical High Cholesterol DYes DNo Prosthesis DYes DNo OtherDependency DYes DNo Kidney Disease DYes DNo Psychiatric Care DYes DNo

EXERCISE WORK ACTIVITY HABITS

D None D Sitting D Smoking Packs/Day

D Moderate D Standing DAlcohol Drinks/Week

DDaily D Light Labor D Coffee/Caffeine Drinks Cups/Day

D Heavy D Heavy Labor D High Stress Level Reason

Falls

Are you pregnant? DYes D No Due Date, _

Injuries/Surgeries you have had Description Date

Head Injuries

Broken Bones

Dislocations

Surgeries

Medications Allergies Vitamins/Herbs/ Minerals

Pharmacy Name _

Pharmacy Phone (__ ) _

Terms of AcceptanceWhen a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working

towards the same objective.Chiropractic care has only one goal. It is important that each patient understand both the objective and the method that will

be used to attain it. This will prevent any confusion or disappointment.Adjustment: An adjustment is the specific application of forces to facilitate the body's correction of spinal nerve

interference. Our chiropractic method of correction is by specific adjustments of the spine.Health: A state of optimal physical, mental and social well-being, not merely the absence ofinfmnity.Vertebral Subluxation: Also known as spinal nerve interference. A misalignment of one or more of the 24 vertebra in the

spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in alessening of the body's innate ability to express its maximum health potential.

We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the courseof a chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice,diagnosis or treatment for those findings, we will recommend that you seek the services of another health care provider.

Regardless of what the disease is called, we do not offer to treat it. Nor do we offer to advice regarding treatment prescribedby others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body's innate wisdom.Our only method is specific adjusting to correct vertebral subluxations.

I, have read and fully understand the above statements.All questions regarding the doctor's objectives pertaining to my care in this office have been answered to my complete satisfaction.

I therefore accept chiropractic care on this basis.

I consent to a professional and complete chiropractic examination and to any radiographic examination that the doctor deemsnecessary. I understand that any fee for service rendered is due at the time of service and cannot be deferred to a later date.

(Signature) (Date)

Consent to evaluate and adjust a minor child

I, being the parent or legal guardian of _have read and fully understand the above terms of acceptance and hereby grant permission for my child to receive

chiropractic care.

(Signature) (Date)

Pregnancy Release

This is to certify that to the best of my knowledge I am not pregnant and the above doctor and his/her associates have my permissionto perform an x-ray evaluation. I have been advised that x-ray can be hazardous to an unborn child. Date of last menstrual period:

(Signature) (Date)

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