Patient History Form

Patient History and Information

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Work or Cell Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

By checking this box I consent to receive an SMS text message to my cell number provided above. You agree to receive informational messages, appointment reminders, & account notifications from Verde Back & Neck Center. Message frequency varies. Message and data rates may apply. For help, reply HELP or email us at info@verdeback.com. You can opt out at any time by replying STOP. You can reply with HELP to get help. See Verde Back & Neck Center's Terms of Service and Privacy Policy.*

YESNO

Email*

example@example.com

Date of Birth*

Date

Age*

Occupation*

Employer*

Do you have health insurance*

NoneMedicareMedicaidOther

How did you hear about this office?*

Previous chiropractic care?*

YesNo

How long ago?*

Did you have a good experience?*

YesNo

Medical history. (PLEASE INCLUDE ALL HEALTH CONDITIONS FOR WHICH YOU’VE BEEN TREATED, OR SUFFER FROM):*

Have you ever had any Surgeries/Hospitalizations? If Yes, list:*

Have you ever had any Traumas/Falls/Accidents? If Yes, list:*

Do you take Drugs/Medications/Supplements? If Yes, list:*

Do you exercise regularly?*

YesNo

What is your reason for visiting our office?*

Have you seen any other doctor’s about this? Y N If yes, list outcome/treatment:*

I certify that all the above information is complete and accurate to the best of my knowledge. I agree to notify this facility immediately whenever I have changes in my health condition or if involved in any accidents in the future. Fees are payable at the time the examination and treatments are received unless other arrangements are made in advance. I hereby give permission for treatment.

Also with my signature I acknowledge that I have been shown or had access to and read the Notice of Privacy Practices, Disclosures and HIPAA forms and I agree with the content within (full forms available anytime upon request).

Signature*

Date*

Date