alignurspine.com - Patient Application Form 2023

PATIENT DEMOGRAPHICS
Name:

First NameLast Name
Birth Date:

MonthDayYear
Date
Age:
Date:

MonthDayYear
Date
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail Address for Doctor Correspondence:
Phone:
Please enter a valid phone number.
Number of children and ages:
Employer/Occupation:
Name & Number of Emergency Contact:
Relationship:
REFERRAL:

Our clinic is primarily referral based. We would like to know who we can thank for sending you to us for help.
Please let us know how you heard about our clinic.
Have you ever been under chiropractic care?
RATE THE IMPORTANCE OF YOUR HEALTH ON A SCALE OF 1-10:

1

2

3

4

5

6

7

8

9

10

1 is Least, 10 is Most
Are there any hobbies or interests that you would like to be able to do again?
Your Top 3 Health Concerns, Goals or Problems

(Mark on the body where you experience symptoms)
Primary:
Secondary:
Mark on the body where you experience symptoms
With 10 being the most severe and 0 being normal, rate your above concerns by selecting the number:
Primary or chief complaint is:

0

1

2

3

4

5

6

7

8

9

10

0 is Normal, 10 is Severe
Second complaint is:

0

1

2

3

4

5

6

7

8

9

10

0 is Normal, 10 is Severe
Third complaint is:

0

1

2

3

4

5

6

7

8

9

10

0 is Normal, 10 is Severe
When did the problem(s) begin?
When is the problem at its worst?

AMPMmid-daylate PM
How long does it last?

It is constantI experience it on and off during the dayIt comes and goes throughout the week
Has this condition ever been treated by anyone in the past?

YesNo
If yes, when:
by whom?
How long were you under care:
How long were you under care:
What were the results?
What relieves your symptoms?
YOUR PAST HISTORY
Please identify any and all types of jobs you have had in the past:

If you have ever been diagnosed with any of the following conditions, please indicate ir by selecting Past, Currently or Never have had:

	Past	Currently	Never
Broken Bone
Dislocations
Tumors
Rheumatoid Arthritis
Fracture
Disability
Cancer
Heart Attack
Osteo Arthritis
Diabetes
Cerebral Vascular

Other serious conditions:

PLEASE identify ALL PAST and any CURRENT conditions you feel may be contributing to your present problem:

	HOW LONG AGO	TYPE OF CARE RECEIVED	BY WHOM
INJURIES
Surgeries
ALL DISEASES IN LIFE

SOCIAL HISTORY
1. Smoking:

cigarspipecigarettes
How often?

DailyWeekendsOccasionallyNever
2. Alcoholic Beverage: consumption occurs

DailyWeekendsOccasionallyNever
3. Recreational Drug use:

DailyWeekendsOccasionallyNever
4. Hobbies -Recreational Activities- Exercise Regime: How does your present problem affect?
FAMILY HISTORY:
1. Does anyone in your family suffer with the same condition(s)?

YesNo
If yes whom:

grandmothergrandfathermotherfathersister(s)brother(s)son(s)daughter(s)
Have they ever been treated for their condition?

YesNoI don't know
2. Any other hereditary conditions the doctor should be aware of?

YesNo
If yes, explain:
I consent and agree to allow this office to treat me, or my child, and use their Patient Health Information for the purpose of treatment, payment, healthcare operations, sharing of testimonials and coordination of care. Initial
I authorize payment to be made directly to Align Your Spine Chiropractic, LLC for all benefits which may be payable under a healthcare plan or from any other collateral sources. I authorize use of this application for the purpose of processing claims, effecting payments, and further acknowledge that this assignment of benefits does not in any way relieve me of payment liability and that I will remain financially responsible to Align Your Spine Chiropractic, LLC for any and all services I receive at this office.
Patient or Authorized Person’s Signature

Clear
Date Completed

MonthDayYear
Date
Should be Empty:

PATIENT DEMOGRAPHICS

REFERRAL:

Your Top 3 Health Concerns, Goals or Problems

YOUR PAST HISTORY

SOCIAL HISTORY

FAMILY HISTORY: