Full Name*:
Date*:
ADDRESS*
CITY*
State:
Zip
Phone (home):
Phone (Work):
Phone (cell):
E-MAIL
ADDRESS:*
Sex:
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Male
Female
Marital Status:
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Single
Separated Married Widowed
Divorced
Date of Birth:
Social Security #
Do you like appointment reminder calls?
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No Thanks
Yes-Cell #
Yes-Home #
Yes-Work #
How
did you hear about our office?:
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Television
Phonebook Ad
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Web Site
Friend or relative
Our location
Card from our staff member
Radio
Door knob ad
Health screening
Other/not listed here
Work
Status:
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Employed
Full time student
Part time student
Other
Emergency
Contact Person:
Emergency Contact Phone:
Your Family
Spouse's
Name:
Date Of Birth:
Spouse's
Social:
Accident Injury Information (Skip this section if your present problems are not related to an accident-injury)
Name of attorney
handling your case
Insurance
Information (Please bring your card and we will check coverage
for you)
Insurance Co.
Group Plan#:
Insured Name:
Your
Injury, Illness or Condition
What is your injury, illness or condition?
Other Condition
Previous interventions, treatments, medications, surgery, or care you've
Do you suffer from any condition
other than that which you are now consulting us?
Previous Chiropractic Care
Have you had previous
Chiropractic care?:
Condition treated:
Results of Treatment:
Month/Year of last
visit:
Health Problems - Check all you have had or have
Prior Surgeries
Date:
Type:
Date:
Type:
Date:
Type:
Current Medications
Name:
Reason:
Name:
Reason:
Name:
Reason:
If your injuries could be due to an AUTO ACCIDENT,
please fill out this section.
Date of
Accident:
Hour of
Accident:
Select
AM PM
Please describe how the collision happened:
What was your position in the car? If Driver, were your hands on the steering wheel?
Select
Both Left Right
Did the airbags deploy?
Select
Yes No
Did you strike another vehicle?
Select
Yes No
Did another vehicle strike you?
Select
Yes No
Angle of Impact: Select Front Back Left Right Other
Angle of 2nd Impact (If applicable): Select Front Back Left Right Other
In relation to the back of your head, was your headrest set: Select Low Middle High
Were you surprised by the impact?Select Yes No
If No, how did you brace?Select With Hands With Feet
Where was your head facing at time of impact? Select Ahead Left Right Behind
Were you leaning forward at the time of impact? Select Yes No
What type and year of vehicle were you in? Your approximate speed? (mph)
Their approximate speed? (mph) What type and year of vehicle struck you? Wearing a belt?
Select
No
Yes
What type?
Select Lap Belt Shoulder Belt Both
Feel pain immediately?
Select
No
Yes
Rendered unconscious?
Select
No
Yes
Check the following if you struck them at the time of impact:
Did your seat break or bend?
Select
No
Yes
Immediately after the accident, how did you feel? (select all that apply)
Select
Dizzy Dazed Weak Upset Disoriented Nervous Nauseous Other
Police and Ambulance Was the accident reported to the police?
Select
Yes
No
Were traffic citations issued?
Select
No
Yes
If yes, to whom? Did you go to the hospital?
Select
Yes
No
If yes, when? If yes, how did you get there?
Select
Ambulance Police Car Private Transportation
Were you admitted? Select
Yes
No If yes, how long? Name of hospital:
Attended by Dr.: What treatments were given?
What other doctor have you seen as a result of this injury? Do you have difficulty in excessive:
Select
Standing Walking Riding Bending Twisting
Do you have difficulty in excessive lifting:
Select
Light Moderate Heavy Repetitive
Symptoms other than above:
Confirmation code: Enter the charactors that appear in the image
Treatment Authorization and Release Today you'll receive a free initial consultation with the doctor. If further tests are needed such as exams or x-rays, the necessity and cost will be explained before they are performed. You'll be happy to know that these tests are covered by most insurances. I hereby authorize this office and its staff and doctors to examine and treat my condition as the doctors deem appropriate. I grant authority for these procedures to be performed. I clearly understand and agree that all services rendered me are charged directly to me and that I am responsible for payment of services by this office. Should collection of past due amount become necessary, I will become responsible for all charges, fees and attorney fees. I (we) hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize the use of this signature on all insurance submissions.
