Patient History Form
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1
2Patient History
Acct #: _______________
Date: _________________
Time: _________________
DI: __________________
Dear Patient:
This form is confidential. We need this information to help us determine if chiropractic can help you. If we do not sincerely believe your
DR: __________________
condition will respond satisfactorily, we will not accept your case. Please be as neat and accurate as possible while completing this form.
PLEASE PRINT.
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P E R S O N A L I N F O R M A T I O N
Name: __________________________________________________ Marital Status: M S W D
Sex: M F
Home Phone: ______________________ Cell: ______________________ E-mail: __________________________________
Address: ___________________________________________________ City: ___________________________________
State: _____________________ Zip: __________ Birthdate: ________________________ Age: _____________________
Social Security #:___________________________ Drivers License #: ____________________________ State: __________
Occupation: _______________________________ Employer's Name: ____________________________________________
Business Phone:
________________________ Employer's Address: ____________________________________________
(
)
Spouse's Name: ____________________________
Spouse's Occupation: ___________________________________________
Spouse's Business Phone:
__________________
Spouse's Employer: ____________________________________________
(
)
Spouse's Birthdate: __________________________
Spouse's Social Security #: ______________________________________
In Case of Emergency Notify: ______________________________________________________________________________
Name, Address, Phone # & Relationship of nearest relative
: _________________________________________________
(not living with you)
_______________________________________________________________________________________________
Who referred you to our office?
: ______________________________________________________________________
(full name)
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I N S U R A N C E I N F O
1st Insurance Company: _________________________________________________________________________________
2nd Insurance Company: _________________________________________________________________________________
Group Membership #: ___________________________________ ID/Policy #: ______________________________________
Type of Insurance:
❑ Group ❑ Private ❑ Auto ❑ Personal Injury ❑ Workers' Compensation ❑ Attorney ❑ Medicare
Name of Insured if different from above: ________________________________________________________________________
Social Security #:___________________________ Date of Birth: ________________________ Relationship: ________________
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P R E S E N T H I S T O R Y
List all your current complaints:
1. _____________________________________________________________________________________________
2. _____________________________________________________________________________________________
3. _____________________________________________________________________________________________
4. _____________________________________________________________________________________________
5. _____________________________________________________________________________________________
Sudden
❑
Date & time of illness / injury: ___________________________________________________________________
Gradual
❑
How did accident occur?
❑ Auto Collision
❑ On the job
❑ Other ____________________________________________________
Have you lost time off work due to this injury?
❑ Yes
❑ No
Dates: ___________________________________________________
Does this condition interfere with your normal daily routine?
❑ Yes ❑ No If yes, explain: _______________________________________
_______________________________________________________________________________________________
Name of primary care physician: _____________________________________ City: __________________________ State: ______
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