• CHIROPRACTIC REGISTRATION AND HISTORY

  • PATIENT INFORMATION

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex
  • Birthdate
     - -
    2 digit month, 2 digit day, 4 digit year
  • Marital Status
  • Format: (000) 000-0000.
  • Birthdate
     - -
    2 digit month, 2 digit day, 4 digit year

  • INSURANCE INFORMATION

  • Is patient covered by additional insurance?
  • Birthdate
     - -
    2 digit month, 2 digit day, 4 digit year
  • SS#
     - -
    2 digit month, 2 digit day, 4 digit year

  • ASSIGNMENT AND RELEASE 
    I certify that l, and/or my dependent(s), have insurance coverage with       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 whether 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 and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • PHONE NUMBERS

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • IN CASE OF EMERGENCY, CONTACT

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • ACCIDENT INFORMATION

  • Is condition due to an accident?
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Type of accident
  • To whom have you made a report of your accident?

  • PATIENT CONDITION

  • Is this condition getting progressively worse?
  • Mark an X on the picture where you continue to have pain, numbness, or tingling.
  • Type of pain:
  • Does it interfere with your
  • Activities or movements that are painful to perform

  • HEALTH HISTORY

  • What treatment have you already received for your condition?

  • Date of Last:

  • Physical Exam
     - -
    2 digit month, 2 digit day, 4 digit year
  • Spinal X-Ray
     - -
    2 digit month, 2 digit day, 4 digit year
  • Blood Test
     - -
    2 digit month, 2 digit day, 4 digit year
  • Spinal Exam
     - -
    2 digit month, 2 digit day, 4 digit year
  • Chest X-Ray
     - -
    2 digit month, 2 digit day, 4 digit year
  • Urine Test
     - -
    2 digit month, 2 digit day, 4 digit year
  • Dental X-Ray
     - -
    2 digit month, 2 digit day, 4 digit year
  • Place check mark to indicate if you have had any of the following:
  • Place check "Yes" or "No" to indicate if you have had any of the following:
    Rows
  • EXERCISE
  • WORK ACTIVITY
  • HABITS
  • Are you pregnant?
  • Due Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Injuries/ Surgeries you have had
    Rows
  • Format: (000) 000-0000.
  • Should be Empty: