CHIROPRACTIC REGISTRATION AND HISTORY
              PATIENT INFORMATION                                                   ...
HEALTH HISTORY
What treatment have you already received for your condition?     Medications  Surgery   Physical Therapy
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All-Star Chiropractic's New Patient History

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New patient? Save yourself some time and complete this 2 page history prior to your first visit to our office.

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All-Star Chiropractic's New Patient History

  1. 1. CHIROPRACTIC REGISTRATION AND HISTORY PATIENT INFORMATION INSURANCE Who is responsible for this account? ________________________ Date ______________________ Relationship to Patient ___________________________________ Patient ________________________________________________ Insurance Co. __________________________________________ Address _______________________________________________ Group # ______________________________________________ ______________________________________________________ Is patient covered by additional insurance? Yes No ______________________________________________________ City State Zip Subscriber’s Name______________________________________ Birthdate ___________________ SS# _____________________ Sex: M F Age ________ Birthday _________________ Relationship to Patient __________________________________ Single Married Widowed Separated Divorced Insurance Co.__________________________________________ Patient SS# ____________________________________________ Group # ______________________________________________ Occupation ____________________________________________ ASSIGNMENT AND RELEASE Employer _____________________________________________ I, the undersigned certify that I (or my dependent) have insurance Employer Address ______________________________________ coverage with __________________________ and assign directly to Dr. Doperak all insurance benefits, if any, otherwise payable to Employer Phone _______________________________________ me for services rendered. I understand that I am financially Spouse’s Name ________________________________________ responsible for all charges whether or not paid by insurance. I herby authorize the doctor to release all information necessary to secure Birthdate___________________ SS# ______________________ the payment of benefits. I authorize the use of this signature on all Occupation ___________________________________________ insurance submissions. Spouse’s Employer _____________________________________ ____________________________________________________ Whom may we thank for referring you? _____________________ Responsible Party Signature _____________________________________ ________________ _____________________________________________________ Relationship Date PHONE NUMBERS ACCIDENT INFORMATION Home___________________ Work_______________ Ext.______ Is condition due to an accident? Yes No Date __________ Best time and place to reach you ___________________________ Type of accident Auto Work Home Other IN CASE OF EMERGENCY, CONTACT To whom have you made a report of your accident? Name_____________________ Relationship _________________ Auto Insurance Employer Worker Comp. Other Home Phone _______________ Work Phone _________________ Attorney Name (if applicable) _____________________________ PATIENT CONDITION Reason for Visit ___________________________________________________________________________________________________ When did your symptoms appear? _________________________________________________ Is this condition getting progressively worse? Yes No Unknown Mark an X on the picture where you continue to have pain, numbness, or tingling. Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain) ______________ Type of pain: Sharp Dull Throbbing Numbness Aching Shooting Burning Tingling Cramps Stiffness Swelling Other How often do you have this pain? _________________________________________________ Is it constant or does it come and go? ______________________________________________ Does it interfere with your Work Sleep Daily Routine Recreation Activities or movements that are painful to perform Sitting Standing Walking Bending Lying Down
  2. 2. HEALTH HISTORY What treatment have you already received for your condition? Medications Surgery Physical Therapy Chiropractic Services None Other ________________________________________________________________ Name and address of other doctor (s) who have treated you for your condition Date of Last: Physical Exam _________________ Spinal X-Ray _____________________ Blood Test ________________________ Spinal Exam ___________________ Chest X-Ray ______________________ Urine Test _______________________ Dental X-Ray __________________ MRI, CT-Scan, Bone Scan _____________________________________________ Place a mark on “Yes” or “No” to indicate if you have had any of the following: AIDS/HIV Yes No Emphysema Yes No Miscarriage Yes No Scarlet Fever Yes No Alcoholism Yes No Epilepsy Yes No Mononucleosis Yes No Stroke Yes No Allergy Shots Yes No Fractures Yes No Multiple Yes No Suicide Attempt Yes No Sclerosis Anemia Yes No Glaucoma Yes No Mumps Yes No Thyroid Yes No Anorexia Yes No Goiter Yes No Problems Osteoporosis Yes No Appendicitis Yes No Gonorrhea Yes No Tonsillitis Yes No Pacemaker Yes No Arthritis Yes No Gout Yes No Tuberculosis Yes No Parkinson’s Yes No Asthma Yes No Heart Disease Yes No disease Tumors, Yes No Bleeding Yes No Hepatitis Yes No Growths Pinched Nerve Yes No Disorders Hernia Yes No Typhoid Fever Yes No Pneumonia Yes No Breast Lump Yes No Herniated Disk Yes No Polio Yes No Ulcers Yes No Bronchitis Yes No Herpes Yes No Prostate Yes No Vaginal Yes No Bulimia Yes No High Yes No Problem Infections Cancer Yes No Cholesterol Prosthesis Yes No Venereal Yes No Cataracts Yes No Kidney Disease Yes No Disease Psychiatric Care Yes No Chemical Yes No Liver Disease Yes No Whooping Yes No Rheumatoid Yes No Dependency Cough Measles Yes No Arthritis Chicken Pox Yes No Other ______________________ Migraine Yes No Rheumatic Yes No Diabetes Yes No Headaches Fever __________________________ EXERCISE WORK ACTIVITY HABITS None Sitting Smoking Packs/Day _____________________ Moderate Standing Alcohol Drinks/Week ____________________ Daily Light Labor Coffee/Caffeine Drinks Cups/Day ______________________ Heavy Heavy Labor High Stress Level Reason ________________________ Are you pregnant? Yes No Due Date ___________________________________ Injuries/Surgeries you have had Description Date Falls ______________________________________________________ ___________________________________ Head Injuries ______________________________________________________ ___________________________________ Broken Bones ______________________________________________________ ___________________________________ Dislocations ______________________________________________________ ___________________________________ Surgeries ______________________________________________________ ___________________________________ MEDICATIONS ALLERGIES VITAMINS/HERBS/MINERALS _____________________________ ________________________ ______________________________________________________ _____________________________ ________________________ ______________________________________________________ Pharmacy Name ________________ ________________________ ______________________________________________________ Pharmacy Phone ________________ ________________________ ______________________________________________________

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