wallstreetchiropractic.com-intakeforms

CHIROPRACTIC REGISTRATION & HISTORY

Patient Information
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
SS/HIC/PATIENT ID #
Patient Name

First NameMiddle NameLast Name
Address
Email
example@example.com
Age
Sex
Marital Status

Partnered for _____Years
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Occupation
Patient Employer/School
Employer/School Address
Employer/School Phone
Please enter a valid phone number.Format: (000) 000-0000.
Spouse's Name
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
SS#
Spouse's Employer
Who may we thank for referring you?
Phone Numbers
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Best time and place to reach you:
Name

First NameLast Name
Relationship
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insurance
Who is responsible for this account?
Relationship to Patient
Insurance co
Group #
Is patient covered by additional Insurance?
Subscriber's Name
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
SS#
Relationship to patient
Insurance Co.
Group #
Assignment and Release
I certify that I. and/or my dependent(s). have insurance coverage with Name of insurance compan(ies)and assign directly to Dr all insurance benefits. if, any otherwise payable to me for services rendered. I understand that I am financially responsible for all charges wheather or not paid by insurance. i authorize the use of my signature on all insurance submissions

The above named doctor may use my health care information and may disclose such information to the above named insurance company(ies) and their agents for the purpose of obtaining payment for services. This Consent will end when my current treatment plan is completed or one year from the date signed below
Signature Paitent, Parent, Guardian or Personal Representative
Please print name of Patient, Parent, Guardian or Personal Representative
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Relationship to Patient
Accident Information
Is condition due to an accident?
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Type of accident

Other
To whom have you made a report of your accident?

Other
Attorney Name(If applicable)
Patient Condition
Reason for visit
When did your symptoms appers?
Is this condition getting progressively worse?
Mark on this picture where you continue to have pain, numbness, or tingling.
Annotate Image
Rate severity of your pain on scale of 1(least pain) to 10(severe pain)
Type of pain

Other
How often do you have this pain?
Is it constant or does it come and go?
Does it interfere with your
Activities or movements that are painfull to perform
Health History
What treatment hane you already received for your condition?

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

Date of Last

Rows
Physical Exam
Spinal Exam
Dental X-Ray
Spinal X-ray

Date of Last

Rows
Chest X-Ray
Blood Test
Urine Test
MRI, CT-Scan, Bone Scan

Mark to indicate if you have had any of the following

Other
Exercise
Work Activity
Habits
Packs/day
Drinks/week
Cups/Day
Reason
Are you pregnent
Due Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Rows	Medications	Allergies	Vitamins/Herbs/Minerals

Pharmacy Name
Pharmacy Phone
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty: