healthchiro.com - New Patient Health History Form

Date

Patient ID #

Patient Name

First NameMiddle NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Sex

MaleFemale

Age

Birthdate

Date

Marital Status

Partnered for how many years?

Occupation

Patient Employer/School

Employer/School Address

Employer/School Phone

Please enter a valid phone number.

Spouse's Name

Spouse's Date of Birth

Date

Spouse's Employer

Whom may we thank for referring you?

Home Phone

Please enter a valid phone number.

Alt. Phone

Please enter a valid phone number.

Best time and place to reach you

IN CASE OF EMERGENCY, CONTACT

Name

Relationship

Home Phone

Please enter a valid phone number.

Alt. Phone

Please enter a valid phone number.

Who is responsible for this account?

Relationship to Patient

Insurance Co.

Group #

Is the patient covered by additional insurance?

YesNo

Subscriber's Name

Birth Date

Date

SS#

Relationship to Patient

Insurance Co.

Group #

ASSIGNMENT AND RELEASE
I certify that I, and/or my dependent(s), have insurance coverage with Name of Insurance Company(ies) and assign directly to Dr. Name of Doctor 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.

Signature of Patient, Parent, Guardian or Personal Representative

Name of Patient, Parent, Guardian or Personal Representative

Relationship to Patient

Date

Is condition due to an accident?

YesNo

Date

Type of Accident:

AutoWorkHome

To whom have you made a report of your accident?

Auto InsuranceEmployerWorker Comp.Other

Attorney Name (if applicable)

Reason for Visit

When did your symptoms appear?

Is this condition getting progressively worse?

YesNoUnknown

Mark an X on the picture to the right where you continue to have pain, numbness or tingling.

Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain)

Type of pain:

How often do you have this pain?

Is it constant or does it come and go?

Does it interfere with your:

SleepWorkDaily RoutineRecreation

Activities or movements that are painful to perform:

	Description	Date
Falls
Head Injuries
Broken Bones
Dislocations
Surgeries

Chiropractic Registration and History

Patient Information

Phone Numbers

Insurance

Accident Information

Patient Condition

Health History