WELCOME

WELCOME
Confidential Health History
- Winston-Salem
- 3570 Vest Mill Road, #B • Winston-Salem, NC 27103
Cary Hall, DC
ABOUT YOU
Today’s Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Name
Birth date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
SS#
Mailing Address
CITY
STATE
ZIP
Cell Phone or Home Phone
Do you reside with a relative?
Do you have children How many?
IN EVENT OF EMERGENCY
Whom should we contact?
Relationship
Home Phone #
Format: (000) 000-0000.
Cell Phone #
Format: (000) 000-0000.
Work Phone #
Format: (000) 000-0000.
Ext
Who is your medical doctor?
Medical doctor’s phone #
Format: (000) 000-0000.
Staff Initials
HOSPITAL / EMERGENCY ROOM
If Yes, which hospital?
Date seen if not taken by ambulance?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Medication: Name of Rx
Other treatment?
Were X-rays taken if yes which body parts x-rayed
If you have a report - please give to our staff - so copy can be made)
Lab work
Follow-up instructions
Did ER doctor write you out of work?
If Yes, give dates

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Did ER doctor write you a work restriction?
If Yes, give dates

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Did you go back to the ER? Date you went back?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If yes, which hospital
4 Is Liringis Chiropractic the only doctor’s office you have been to for this accident? If no, fill in the following:
OTHER MEDICAL PROVIDERS OTHER THAN HOSPITAL/EMERGENCY ROOM
Doctor
Date first seen

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
X-rays Made? If so, which area was taken
Currently treating? Yes or No
If Yes, give date Did a Doctor or Physican Assistant write you out of work?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Did a Doctor or Physican Assistant write you a work restriction? Yes No If Yes, give dates

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Special test
Referred to
HEALTH HISTORY
1.List any diagnosis and/or treatments
2.List any unusual diseases and year or occurrence/diagnosis
3.Have you been treated for any health condition in the past year
4.Have you received chiropractic treatment previously? If yes, explain
5.How did you feel before the accident?

Family History

Rows	Diseases in the Family? (Arthritis, Heart Disease, Cancer, Diabetes, Multiple Sclerosis)	-	Living or Deceased?
Mother
Father
Brothers
Sisters
Grandmother (s)
Grandfather (s)

Doctor’s Initials:
Staff Initials
2.Please list any surgeries with dates and/or other serious medical condition(s) not listed above

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
3.List any past serious accidents with dates

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
4.Please list anything that you may be allergic to
5.Do you take supplements or vitamins? Do you exercise? o Yes o No
6.Do you smoke? o Yes o No How much?
How long?
7.For women: Are you taking birth control? o Yes o No Are you nursing? o Yes o No
8.Are you pregnant? o Yes o No If so, how many weeks?
Current Medication
Dosage
We invite you to discuss with us any questions regarding our services. The best health services are based on a friendly, mutual understanding between provider and patient.

HIPAA Compliance - Our office is required by law to maintain the HIPAA Notice of Privacy Practices. This notice explains our legal duties and privacy practices with respect to your protected health insurance. Signature below acknowledges that I have read this Notice of our Privacy Practices. A copy will be provided to me upon request.

I authorize the staff to perform any necessary medical services needed during diagnosis and treatment.

I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided.
Patient Signature: Staff Signature
Date: Date
Date: Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Doctor’s Initials:
Staff Initials
Should be Empty:

WELCOME

Confidential Health History

Cary Hall, DC

ABOUT YOU

IN EVENT OF EMERGENCY

HOSPITAL / EMERGENCY ROOM

OTHER MEDICAL PROVIDERS OTHER THAN HOSPITAL/EMERGENCY ROOM

HEALTH HISTORY