1. Welcome...We are glad you’re here!
Please describe your major complaint ________________________________________________________
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Was this problem due to _____ Auto accident — Date: _________________
_____ Work accident — Date: ________________
_____ Other
When noticed (if accident or injury please describe) ____________________________________________
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How does this interfere with normal living? __________________________________________________
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What activities make it worse? ____________________________________________________________
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Have you had treatment for same or similar condition? _________________________________________
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What have you done to treat this condition? __________________________________________________
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Please List: 1. Past Injuries ______________________________________________________________
2. Auto Accidents ___________________________________________________________
3. Major Illness (include year/type)______________________________________________
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4. Operations/Surgery (include year/type) ________________________________________
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5. Other doctors seen (and for what condition) _____________________________________
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Are you taking any medication (and for what)? ________________________________________________
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Any known Allergies to Medications?_______________________________________________________
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Do you some or use tobacco? ______________________________
Have you been diagnosed or treated for Hypertension (high blood pressure)? Yes: _____ No: _____
Previous chiropractic care (Dr. name and date of last visit)? ______________________________________
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3. Name ______________________________________________ Date ________________________________
Address _______________________________________ City____________ State ____ Zip _____________
Social Security Number _____________________________ Birth Date __________________ Age ________
Phone (home) ________________ (cell) _________________ Cell Phone Company _____________________
(to text reminders)
Primary Language Spoken: ________________ Race: _______ Ethnicity: Non-Hispanic: __ Hispanic: __ Other ___
Sex: M F Marital Status: M S W D Sep Email address ____________________________________________
Employer __________________________ Occupation ____________________ Work Phone ____________
Spouse Name ____________________________________ Number of Children _______________________
Who may we thank for referring you? __________________________________________________________
Name of your Medical Doctor ________________________________________________________________
Name of emergency contact person: ____________________________ Relation: ______________________
Address _________________________________________________ Phone __________________________
Employer _______________________________________________ Phone __________________________
 It is your responsibility to notify us when you have a change in
your insurance information
Insurance Information: Please present your insurance card to be copied for our records.
Supplemental Insurance ? _____________________________________________________________________
_____Personal Injury/Auto Accident Name/Address of Company __________________________________
Claim # _________________________ Adjuster’s Name ___________________________________
Is an attorney representing you in this case? Y N
Name of Attorney ___________________________________ Phone __________________________
_____Other name and Address of Company _____________________________________________________
ID &/or group # ____________________________________________________________________
I certify that the above information is true and correct. I hereby authorize the release of any information required. I also author-
ize my benefit payments to be paid directly to this office. I am financially responsible for non-covered services. If accepted as a
patient at Patrick Chiropractic, I authorize any treatment which may be necessary. Any risks regarding Chiropractic Care will be
explained upon my request.
Fees are due at the time service is rendered.
I plan to pay be: _________ Cash ___________ Check ______________ Credit/Debit Card
Date ______________________________ Patient/Guardian Signature _______________________________