New Patient Form

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Chiropractic Case History/Patient Information

Name:      Home Phone:      Cell Phone:

Address:      City:      State:       Zip:

Email Address:      Age:      Birth Date:      Marital:      Occupation:

Employer:      Employer's Address:      Office Phone:

Spouse:      Occupation:       Employer:

Emergency Contact:      Phone:      How Many Children?:

Names and Ages of Children:

Whom May We Thank For Referring You?:      Family Medical Doctor:

When doctors work together it benefits you. May we have your permission to update your medical doctor regarding your care at this office? Yes No

Please Check Any and All Insurance Coverage That May Be Applicable in This Case:
Major Medical Worker's Compensation Medicaid Medicare Auto Accident Medical Savings Account and Flex Plans
Other
Name of Primary Insurance Company: Name of Secondary Insurance Company:

AUTHORIZATION AND RELEASE: I authorize payment of insurance benefits directly to the chiropractor or chiropractic office. I authorize the doctor to release all information necessary to communicate with personal physicians and other healthcare providers and payors and to secure the payment of benefits. I understand that I am responsible for all costs of chiropractic care, regardless of insurance coverage. I also understand that if I suspend or terminate my schedule of care as determined by my treating doctor, any fees for professional services will be immediately due and payable.

The patient understands and agrees to allow Spine & Sports Chiropractic to use their Patient Health Information for the purpose of treatment, payment, healthcare operations, and coordination of care. We want you to know how your Patient Health Information is going to be used in this office and your rights concerning those records. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent. The following person(s) have my permission to receive my personal health information:

I have read the Authorization and Release(*REQUIRED)

History Of Present and Past Illness:

Describe your major complaint(s):      Date symptoms appeared:

Describe how they began:      Is it due to: Auto Work Other

Have you ever had the same or a similar condition? Yes No

How often do you experience these symptoms:
Constantly (76%- 100% of the day)
Frequently (51% - 75% of the day)
Occassionaly (26% - 50% of the day)
Intermittently (0% - 25% of the day)

How would your describe the symptoms?
Sharp Shooting Stabbing Weakness Dull Stiffness
Numb Tingling Cramps Achy Burning Throbbing

How are your symptoms changing?
Getting better Getting worse No change

How would you rate your symptoms:      At Their Best:      At Their Best Worst:
How do your symptoms affect your ability to perform you daily living activities and at work?
What makes your symptoms worse?
What makes your symptoms better?

Have you ever received chirorpactic care for this condition? Yes No
If yes list provider:
Provider      Address      Date Seen

Have you had any other tests done for your symptoms? Yes No
If yes, please give date.
X-rays      MRI      CT Scan      Lab      Other

Have you ever received chiropractic care before?
Yes No If yes, please list:
Name      Address      Date Seen

For each of the conditions listed below, place a check in the past column if you have had the condition in the past. If you presently have a condition listed below, place a check in the Present column.

Past	Present		Past	Present		Past	Present
		Headaches			High Blood Pressure			Diabetes
		Neck Pain			Heart Attack			Excessive Thirst
		Upper Back Pain			Chest Pains			Frequent Urination
		Mid Back Pain			Stroke			Chronic Sinusitis
		Low Back Pain			Angina			Smoking/Use Tobacco Products
		Shoulder Pain			Kidney Stones			Drug/Alcohol Dependence
		Elbow/Upper Arm Pain			Kidney Disorders			Allergies
		Wrist Pain			Bladder Infection			Depression
		Hand Pain			Painful Urination			Systemic Lupus
		Hip/Upper Leg Pain			Loss of Bladder Control			Epilepsy
		Knee/Lower Leg Pain			Prostate Problems			Dermatitis/Eczema/Rash
		Ankle Foot Pain			Abnormal Weight Loss/Gain			HIV/AIDS
		Jaw Pain			Loss of Appetite	Females Only
		Joint Swelling/Stiffness			Abdominal Pain			Birth Control Pills
		Arthritis			Ulcer			Hormonal Replacement
		Rheumatoid Arthritis			Hepatitis			Pregnancy
		General Fatigue			Liver/Gall Bladder Disorder	Other Health Issues
		Muscular Incoordination			Cancer
		Visual Disturbances			Tumor
		Dizziness			Asthma

List all Prescription and over-the-counter medications, and nutritional / herbal supplements you are taking:

List all the surgical procedures you have had and the times you have been hospitalized:
Doctor's Additional Comments:

SOCIAL / WORK HISTORY

Exercise: Work Activity: Smoking (packs/day if applicable) Drinking (drinks/week if applicable)
Caffeine (cups/day if applicable) Stress (Reason)

FAMILY HISTORY

Please review the below-listed diseases and conditions and indicate those that are current health problems of the family member. Leave blank those spaces that do not apply.

Condition	Father	Mother	Spouse	Brother(s)	Sister(s)	Children
Arthritis
Back Trouble
Bursitis
Cancer
Constipation
Diabetes
Disc Problem
Emphysema
Epilepsy
Headaches
Heart Trouble
High Blood Pressure
Insomnia
Kidney Trouble
Liver Trouble
Migraine
Nervousness
Neuritis
Neuralgia
Pinched Nerve
Scoliosis
Sinus Trouble
Stomach Trouble

If any of the above family members are deceased, please list their age at death and cause: I certify the information provided is accurate to the best of my knowledge (required):

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New Patient Form

Chiropractic Case History/Patient Information

History Of Present and Past Illness:

SOCIAL / WORK HISTORY

FAMILY HISTORY