Please complete this form using your keyboard, then print it using the print function of your browser.  You can then sign the form and bring it with you to your first appointment. This form will not be submitted via the Internet, so security is not an issue.

Home Phone:   Age       Birth Date  Sex    M   F

Social Security #  Driver's License Number:

Social Insurance #    Marital: M S W D       

Employer Type of work

Office Phone          Spouse's Social Security #

Name of spouse    Spouse's Social Insurance #

Spouse's Employer       Office Phone

Type of work        

Name & ages of children

Name & Number of emergency contact Relationship:

Who is responsible for your bill, you and  spouse    Workers' Comp   Auto Insurance   Medicare

 Medicaid     Personal Insurance (name) Health Card # 

Insured Person's Name    Date of birth

Current Health Condition

Unwanted health condition

Other doctors seen for this conditions Yes   No   Who

Type of treatment    Results

When did this condition begin?    Has this condition occurred before? Yes   No 

Is Condition: Job related   Auto accident   Home injury   Fall   Other:

Date of accident Time of accident

Have you made a report of your accident to your employer? Yes   No 

Drugs you take now: Nerve pills    Pain killers/muscle relaxers    Blood pressure medicine  Insulin

Other:

Do you wear a shoe lift? Yes   No 

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

Caused by:

Past Health History

Major Surgery/Operations: Appendectomy     Tonsillectomy    Gall Bladder    Hernia    Broken Bone(s)   

____________________     ________________________     _____________________

Major Accidents or Falls:

Hospitalization (other than above):

Have you had previous chiropractic care? Yes    No Doctor's Name

Below is a list of conditions which may seem unrelated to the purpose of your appointment. However, these questions must be answered carefully as these problems can affect your overall diagnosis, treatment plan, and possibility of being accepted for care.

Please check any of the following diseases that you have had:

Appendicitis             Malaria                      Chicken Pox          Alcoholism

Scarlet Fever             Tuberculosis              Diabetes                Venereal Infection

Diphtheria                Whooping Cough    Cancer                  Arthritis

Typhoid Fever          Anemia                      Heart Disease       Epilepsy

Pneumonia               Measles                      Goiter                   Mental Disorder

Rheumatic Fever       Mumps                      Influenza              Lumbago

Polio                          Small Pox                  Pleurisy                 Eczema

Auto-Immune Deficiency Syndrome (HIV)

Please check any of the following you now have or have had in the past 6 months.

Musculo-Skeletal Code                             Constipation                                     Male/Female Codes

Low back pain                                 Hemorrhoids                                      Menstrual Irregularity

Pain between shoulders                   Liver Trouble                                      Menstrual Cramping

Neck pain                                        Gall Bladder Problems                        Vaginal Pain/Infections

Arm pain                                          Weight Troubles                                 Breast Pain/Lumps

Joint pain/stiffness                          Abdominal Cramps                             Prostate/Sexual Dysfunction

Walking problems                            Gas/Bloating after meals                    Genital Herpes

Difficulty chewing/clicking jaw      Heartburn                                           Females only:

                                                                  Black/Bloody Stool                              When was your last period?

Nervous System Code                                  Colitis                                                Are you pregnant? Yes    

Numbness                                 Genito-Urinary Code                                

Paralysis                                 Bladder Trouble

Dizziness                                Painful/Excessive Urination

Forgetfulness                         Discolored Urine

Confusion/Depression             C-V-R Code

Fainting                                  Chest Pain

Convulsions                            Short Breath

Cold/Tingling Extremities      Blood Pressure Problems

General Code                                   Irregular Heartbeat                Please outline on the diagram your area of pain.

Allergies                                   Heart Problems

Loss of sleep                             Lung Problems/Congestion

Fever                                        Varicose Veins

Headaches                                Ankle Swelling

Gastro-Intestinal Code                     EENT Code

Poor/Excessive Appetite           Vision Problems

Excessive Thirst                       Dental Problems

Frequent Nausea                      Sore Throat

Vomiting                                  Ear Ache             

Diarrhea                                   Hearing Difficulty

                                                          Stuffed Nose

Do Not Write Between These Lines.

Analysis: ___________________________________________________________________

Diagnosis: _________________________________________________________________

Patient Accepted: Yes         No                                 ___________________________________

                                                                                                        Doctor's Signature

Most patients that come to our office have one of two objectives in mind concerning their healthcare. Some patients come for symptomatic relief of pain or discomfort (Relief Care). Others are interested in having the cause of the problem as well as the symptoms corrected and relieved (Corrective Care). Your Doctor will weigh your needs and desires when recommending your treatment program.

Please check the type of care desired so that we may be guided by your wishes whenever possible.

Relief Care             Corrective Care        I want the Doctor to select the type of care appropriate for my condition.

Benefits Assigned

Patient's Signature   Date

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that the Doctor's Office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to the Doctor's Office will be credited to my account on receipt. However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will be immediately due and payable.

I hereby authorize the Doctor to treat my condition, as he deems appropriate through the use of manipulation throughout my spine and also understand any risk associated with such manipulation. It is understood and agreed the amount paid the Doctor for x- rays is for examination only and the x-ray negatives will remain the property of this office, being on file where they may be seen at any time while a patient of this office. The patient also agrees that he/she is responsible for all bills incurred at this office. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis.

Patient's Signature                    Date

Consent to Treat Minor             Date

Guardian or Spouse's Signature Authorizing Care   Date