Rubertchiropractic.com - Patient History

Thank you for allowing us to address your health needs. The information on this questionnaire will help us determine if chiropractic care can help you. If we do not sincerely believe your condition will respond satisfactorily, we will not accept your case.

First NameMiddle NameLast Name

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

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SingleMarriedDivorcedWidowed

First NameMiddle NameLast Name

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Every Day SmokerOccasional SmokerFormer SmokerNever Smoked

Hispanic/LatinoNot Hispanic/LatinoDecline to Answer

Work Related InjuryAutomobile AccidentOther Injury/Fall

*Please inform the front desk, as additional paperwork and appointment time may be required.

Doctors you have seen for this condition:

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Many health problems are a result of hereditary conditions.Therefore, information about your family will give us a better understanding of your total health picture.

How many hours do you:

	Right	Left	Both
Head
Mid Back
Arm
Legs
Chest
Low Back
Wrist
Knees
Stomach
Shoulder
Hand
Ankles
Neck
Elbow
Hips
Feet

I understand the above information and guarantee this form was completed correctly to the best of my knowledge. I also understand it is my responsibility to inform this office of any changes in my health or insurance status.

Confidential Patient Case History

ABOUT YOU:

SPOUSE CONTACT INFORMATION:

ADDITIONAL EMERGENCY CONTACT INFORMATION

ELECTRONIC HEALTH RECORDS (EHR) INTAKE:

ABOUT YOUR CONDITION:

FAMILY HEALTH HISTORY:

GENERAL HEALTH HABITS:

YOUR HEALTH HISTORY: