midlandschiropractic.com - Patient Information

Confidential Patient Data
IF YOU NEED ANY ASSISTANCE COMPLETING THIS FORM, PLEASE ASK THE RECEPTIONIST

Beginning April 2016, there will be an after-hours charge for visits that exceed regular business hours.
PATIENT INFORMATION
Today's Date:

MonthDayYear
Date
Name:
Date of Birth:

MonthDayYear
Date
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:
Please enter a valid phone number.
Cell Phone:
Please enter a valid phone number.
Work Phone:
Please enter a valid phone number.
Email Address:
example@example.com
Would you like to receive our monthly newsletters via email?

YesNo
Would you like an email message reminder for scheduled appointments:

YesNo
Would you like a text message reminder for scheduled appointments:

YesNo
(PLEASE PUT DOWN A CELL PHONE NUMBER AND YOUR PROVIDER (Verizon, AT&T, etc):
Social Security #:
Age:
Gender:

MaleFemale
Marital Status:

MarriedSingleDivorcedSeparatedOther
Name of Spouse/Emergency Contact:
Phone Number:
Please enter a valid phone number.
Your Occupation:
Your Employer:
How did you hear about our office:

FriendFamily MemberNewspaperRadioClinic LocationGoogleOther
Family Member -Name?
Payment for Services will be by:

CashCheckCredit CardHealth Insurance
Name of Insurance Co.:
Policy Holder:
Policy Holder's DOB:

MonthDayYear
Date
ID Card #:
Policy Holder's Employer:
Employer's Phone #:
Please enter a valid phone number.
Are you covered by more than one insurance company?

YesNo
Name:
MEDICAL/FAMILY HISTORY

S = Self, M = Mother, F = Father

Please indicate which conditions have been experienced by the above by marking appropriate boxes

	Self	Mother	Father
AIDS
Anemia
Arthritis
Asthma
Back pain
Bladder trouble
Bone fracture
Cancer
Chest pain
Concussion
Convulsions
Diabetes
Indigestion
Dislocated joints
Epilepsy
German measles
Headaches
Heart trouble
Reproductive disorders
High blood pressure
HIV/ARC
Kidney disorder
Bowel control loss
Menstrual cramps
Multiple sclerosis
Muscular dystrophy
Neck pain
Nervousness
Numbness
Polio
Poor circulation
Hepatitis
Rheumatic fever
Rheumatism
Scarlet fever
Serious injury
Sinus trouble
Tuberculosis
Venereal disease

Confidential Patient Data

PATIENT INFORMATION

MEDICAL/FAMILY HISTORY

SURGICAL HISTORY:

ACCIDENT HISTORY:

PLEASE DESCRIBE PRESENT MAJOR COMPLAINTS:

	Symptom	Rate out of 10
1
2
3
4
5