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Patient Info Form

Full Name
Date of Birth
Gender	MaleFemale
Street Address
Address Line 2
City
State	select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware DC Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
Zip Code
Home Phone
Work Phone
Cell Phone
Please indicate your preferred contact number	HomeWorkCell
Email Address
Referred By
Occupation
Employer
Medical History
Describe your symptoms, please be as specific as possible
Please indicate which side is being affected	Right side Left side Center Bilateral (both sides) Other (please describe below)
If Other, please describe where you are being effected
What caused them?
How long have you had this condition?
What relieves them?
Does it change, move or spread?
What bothers you the most about this condition?
Have you ever been diagnosed as having or have suffered from (Please check conditions that apply to you)	Anemia Osteoarthritis Rheumatoid Arthritis Eating Disorder Depression / Anxiety Alcohol / Drug Addiction Diabetes Heart Disease High / Low Blood Pressure Stroke / TIAs Detached Retina Deep Vein Thrombosis HIV Positive Congenital Diseases Seizures / Convulsions Cancer
Enter any other applicable conditions
Surgeries, Serious Illnesses or Injuries? Women, please include information about childbirth (dates and outcome)
Trauma / Fractures (dates and outcome)
Workers' Comp/Personal Injuries (date, TX, outcome)
Sports or other injuries to head, neck or back
Military Injuries
Name and contact information of your Primary Care Physician
Current Medications (Prescriptions, over the counter & supplements)
Do you have any allergies to any medication? Please desribe
Do you have any allergies of any kind? Please describe
Please list any other health concerns or anything else you would like for us to know
Prior treatment by a Chiropractor & date
Do you drink alcoholic beverages?	YesNo
If so, how many drinks per week	Select 1 or 2 3 or 4 5 or 6 7 or 8 9 or more
Do you use any tobacco products?	YesNo
If so, packs/containers per day	Select 0.5 1 1.5 2 2.5 3 or more
Do you consume caffeine?	YesNo
Cups per day	Select 1 2 3 4 5 or more
Do you exercise?	YesNo
If yes, how many times per week and what type of exercise?
What are your hobbies?
What percentage of the date do you normally spend:
Lifting	0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Sitting	0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Bending	0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Computer	0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Driving	0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Insurance Information
Name as listed on insurance card
Policy Holder	Self Spouse Parent
Name of policy holder listed on the card, if other than self
Insurance Carrier (Ex: BCBS, Aetna)
Insurance plan name (Ex: Blue options, Choice Pos II)
Insurance ID number
Insurance group number
Insurance carrier address
Insurance carrier provider phone number
Security	Retype the numbers below:   --

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