Personal History Form
Full Name: Date:
Address: City:
State: Zip:
Phone (home):   Phone (work):
Phone (cell):   Email address:
Sex: Marital Status: Date of Birth:
Social Security #  
How did you hear about our office?:  
Work Status:   
Emergency Contact Person:
Emergency Contact Relationship: Phone:
 
Your Family
Spouse's Name: Date Of Birth:
Spouse's Social
 

Accident Injury Information
Could your present problems be due to an accident-injury? Date:
Type of Accident-injury: Auto  On-the-Job  Sports  Military  Household  Slip/Fall  Personal 
Other
Name of attorney handling your case:
Phone: Fax:

Insurance Information (Please bring your card and we will check coverage for you)
Type of Insurance you plan to use to help pay your account
Auto  On-the-Job  Health Medicare    Other Self-pay
Insurance Co. Policy #:
Group Plan#:

Insured Name: Insured's DOB:

I have dual coverage and will bring the information in with me


Your Injury, Illness or Condition
What is your injury, illness or condition?

Other Condition
Do you suffer from any condition other than that which you are now consulting us?
 

Previous Chiropractic Care
Name of Chiropractor:
Condition treated: Results of Treatment:
Month/Year of last visit:

Health Problems - Check all you have had or have
Low Back Pain Fractured Bones Spinal Taps Fainting
Arm Pain Dislocation Scoliosis Birth Defects
Headaches Joint Replacement Diabetes Osteoporosis
Neck pain Metal Screws/Implants High Blood Pressure Cancer
Pain Between Shoulders Cervical Whiplash Stroke Tumor
Leg Pain Electronic Implant Aneurysm Cyst
Cold/Tingling Extremities Pacemaker Convulsions Ear Infections
Numbness Ruptured Spinal Disc Seizures Birth Complications
Allergies Slipped Spinal Disc Memory Lapse Asthma
Loss of Sleep Pinched Nerve Dizziness Bed Wetting
Stomach/Digestive problem Spinal Surgery Concussion Spinal Injections
Walking Problem Knocked Unconscious Heart Disease Fever
     
Are you pregnant? Other serious illness

If your injuries could be due to an AUTO ACCIDENT, please fill out this section
Accident Patient History
Date of Accident Time
Were you?: Driver  Passenger  Front Seat  Back Seat
Were you wearing a seat belt? Shoulder Harness?
Description of Accident
Were you struck:
From Behind  In Front  Right Front  Right Middle  Right Rear 
Left Front  Left Middle  Left Rear
Were you: Moving  Stopped  Turning Right  Turning Left
Approximate speed of automobiles at time of impact:
Did you see the accident coming?       Yes     No

Which way were you looking at the time of impact?

Upon impact which way was your body thrown? Forward  Backward  Right  Left
Did you hit your head on anything?
Yes     No		 What?
Lose consciousness?
Yes     No		 How Long?
Amount of Damage to vehicle?
Type of vehicle?
Police report filed? Yes     No
Citation issued? Yes     No To whom?
When did the pain begin?
Since Motor Vehicle Accident - Pain is: Less  Same  Worse
Transported to hospital? Yes     No Hospital Name:
X-rays taken?   Yes     No
Instructions from ER Doctor:
Have you seen another Dr.since the accident?  Yes     No
Dr. Name
What Treatment did you receive

Criteria to be accepted as a Patient
Unfortunately, we cannot accept everyone as a patient so patients are accepted on a necessity and patient commitment criteria.

1. We must feel your condition is serious enough to necessitate treatment
2. We must feel we will have very favorable results from your treatment.
3. In the event you cannot make an appointment you agree to call in advance to reschedule.

.
Treatment Authorization and Release
I hereby authorize this office and its staff and doctors to examine and treat my condition as the doctors deem appropriate and I give 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 including all outside laboratory or radiology services performed on my behalf. Should collection of past due amount become necessary, I will become responsible for all charges, collection fees and attorney fees. I (we) hereby authorize the doctor to release all information necessary to secure payment of benefits. I understand that statements made in any video presentation are made by non doctors and to insure a high quality of care, a supervisor may monitor open treatment areas. I authorize the use of this signature on all insurance submissions and I certify my sole purpose of entering this office is for healthcare.

 

This form will be emailed to our clinic when you press submit. I understand that internet email is not secure or encrypted.