laceywellnesscenter.com - New Patient Form

WELCOME!
ABOUT YOU
Today's Date:

MonthDayYear
Date
Patient Name:

First NameMiddle NameLast Name
What you prefer to be called?
Gender:

MaleFemale
Birthdate:

MonthDayYear
Date
Age:
SS#:
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone #:
Please enter a valid phone number.
Work Phone #:
Please enter a valid phone number.
Other Phone #:
Please enter a valid phone number.
Email Address:
example@example.com
Referred By:
Employer:
How Long?
Employer's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation:
Status:

SingleMinorMarriedDivorcedWidowedSeparated
Spouse's Name:
Do you have children?

YesNo
How many?
INSURANCE INFO
Primary Insurance
Co. Name:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Insured's SS#:
Group # (Plan, Local, or Policy #):
Insured's Name:
Relation:
Date of Birth:

MonthDayYear
Date
Insured's Employer:
Secondary Insurance
Co. Name:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Insured's SS#:
Group # (Plan, Local, or Policy #):
Insured's Name:
Relation:
Date of Birth:

MonthDayYear
Date
Insured's Employer:
ACCOUNT INFO

Person ultimately responsible for account
Name:
Relation:
Billing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SS#:
Drivers License #:
Work Phone #:
Please enter a valid phone number.
Payment method:

Cash CheckCredit Card
Initial I hereby authorize assignment of my insurance Initials rights and benefits directly to the provider for services rendered. I fully understand I am solely responsible for any balance not paid by my insurance company (if offered at this office).
IN EVENT OF EMERGENCY
Who should we contact?
Relation:
Home Phone #:
Please enter a valid phone number.
Work Phone #:
Please enter a valid phone number.
Who is your Medical Doctor?
M.D.'s Phone #:
Please enter a valid phone number.
REASON FOR VISIT
Reason for today's visit:

EmergencyNew InjuryOld InjuryChronic PainWellness
Are you in pain?

YesNo
Rate your pain with the following scale:

1

2

3

4

5

6

7

8

9

10

1 is Discomfort, 10 is Intense
Did your injury occur during:

WorkSports/playAuto AccidentRoutine/Household activity
When did your condition/accident occur?
Where did your injury occur?
Please explain what happened:
Is your condition getting worse?

YesNoConstantComes and goes
Is your condition interfering with your:

WorkSleepDaily routine?
If so, how:
Has this or something similar happened in the past?

YesNo
Explain:
Using the below body diagram. Circle on all affected areas.
Have you been treated by a Medical Physician for this condition?

YesNo
If so, where?
Have you ever been treated by a Chiropractor?

YesNo
Clinic or Dr's name:.
Clinic phone#:
Please enter a valid phone number.
HEALTH HISTORY
Are you taking any of the following medications?

Nerve pillsPain killers (including aspirin)Muscle relaxersBlood ThinnersTranquilizersInsulinOther

Do you have or have you had any of the following diseases, medical conditions or procedures?

	Yes	No
Heart Attack / Stroke
Artificial Valves
Shingles
High/Low Blood Pressure
Ulcers/Colitis
Difficulty Breathing
Heart Surg./Pacemaker
Heart Murmur
Alcohol/Drug Abuse
Cancer
Venereal Disease
Frequent Neck Pain
Psychiatric Problems
Rheumatic Fever
Fainting/Seizures/Epilepsy
Sinus Problems
Chemotherapy
Congenital Heart Defect
Hepatitis
Glaucoma
Mitral Valve Prolapse
HIV+/AIDS/ARC
Anemia / Diabetes
Severe / Frequent Headaches
Kidney Problems
Emphysema / Asthma
Tuberculosis
Lower Back Problems
Artificial Bones/Joints/Implants
Arthritis

Please list any surgeries with dates and/or any other serious medical condition(s) not listed above:
List any past serious accidents with dates:
Please list anything that you may be allergic to:
Family Health History:
Do you take Supplements or Vitamins?

YesNo
Do you exercise?

YesNo
Hours per week
Do you smoke?

YesNo
How much?
How long?
Are you wearing:

Shoe liftsInner solesArch supports
Are you dieting?

YesNo
Since:
For women:
Are you taking Birth Control?

YesNo
Are you Nursing?

YesNo
Are you Pregnant?

YesNo
If so, how many weeks?
- We invite you to discuss with us any questions regarding our services. The best health services are based on a friendly, mutual understanding between provider and patient.
- Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with the business manager. If account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, interest charges and any other expenses incurred in collecting your account.
- I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider to release any information required to process insurance claims.
- I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

WELCOME!

ABOUT YOU

INSURANCE INFO

Primary Insurance

Secondary Insurance

ACCOUNT INFO

IN EVENT OF EMERGENCY

REASON FOR VISIT

HEALTH HISTORY

For women: