ACCIDENT INFORMATION Is condition due to an accident? Yes No Date __________

Type of accident Auto Work Home Other

To whom have you made a report of your accident?

Auto Insurance Employer Worker Comp. Other

Attorney Name (if applicable) _____________________________

INSURANCE

PATIENT CONDITION

PATIENT INFORMATION

CHIROPRACTIC REGISTRATION AND HISTORY

Who is responsible for this account? ________________________

Relationship to Patient ___________________________________

Insurance Co. __________________________________________

Group # ______________________________________________

Is patient covered by additional insurance? Yes No

Subscriber’s Name______________________________________

Birthdate ___________________ SS# _____________________

Relationship to Patient __________________________________

Insurance Co.__________________________________________

Group # ______________________________________________

ASSIGNMENT AND RELEASE I, the undersigned certify that I (or my dependent) have insurance coverage with __________________________ and assign directly to Dr. Doperak all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I herby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. ____________________________________________________ Responsible Party Signature _____________________________________ ________________ Relationship Date

PHONE NUMBERS Home___________________ Work_______________ Ext.______

Best time and place to reach you ___________________________

IN CASE OF EMERGENCY, CONTACT

Name_____________________ Relationship _________________

Home Phone _______________ Work Phone _________________

Date ______________________

Patient ________________________________________________

Address _______________________________________________

______________________________________________________

______________________________________________________

City State Zip

Sex: M F Age ________ Birthday _________________

Single Married Widowed Separated Divorced

Patient SS# ____________________________________________

Occupation ____________________________________________

Employer _____________________________________________

Employer Address ______________________________________

Employer Phone _______________________________________

Spouse’s Name ________________________________________

Birthdate___________________ SS# ______________________

Occupation ___________________________________________

Spouse’s Employer _____________________________________

Whom may we thank for referring you? _____________________

_____________________________________________________

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

AIDS/HIV Yes No

Alcoholism Yes No

Allergy Shots Yes No

Anemia Yes No

Anorexia Yes No

Appendicitis Yes No

Arthritis Yes No

Asthma Yes No

Bleeding Disorders

Yes No

Breast Lump Yes No

Bronchitis Yes No

Bulimia Yes No

Cancer Yes No

Cataracts Yes No

Chemical Dependency

Yes No

Chicken Pox Yes No

Diabetes Yes No

Scarlet Fever Yes No

Stroke Yes No

Suicide Attempt Yes No

Thyroid Problems

Yes No

Tonsillitis Yes No

Tuberculosis Yes No

Tumors, Growths

Yes No

Typhoid Fever Yes No

Ulcers Yes No

Vaginal Infections

Yes No

Venereal Disease

Yes No

Whooping Cough

Yes No

Other ______________________ __________________________

HEALTH HISTORY

Emphysema Yes No

Epilepsy Yes No

Fractures Yes No

Glaucoma Yes No

Goiter Yes No

Gonorrhea Yes No

Gout Yes No

Heart Disease Yes No

Hepatitis Yes No

Hernia Yes No

Herniated Disk Yes No

Herpes Yes No

High Cholesterol

Yes No

Kidney Disease Yes No

Liver Disease Yes No

Measles Yes No

Migraine Headaches

Yes No

Miscarriage Yes No

Mononucleosis Yes No

Multiple Sclerosis

Yes No

Mumps Yes No

Osteoporosis Yes No

Pacemaker Yes No

Parkinson’s disease

Yes No

Pinched Nerve Yes No

Pneumonia Yes No

Polio Yes No

Prostate Problem

Yes No

Prosthesis Yes No

Psychiatric Care Yes No

Rheumatoid Arthritis

Yes No

Rheumatic Fever

Yes No

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 ________________________

Injuries/Surgeries you have had Description Date Falls ______________________________________________________ ___________________________________ Head Injuries ______________________________________________________ ___________________________________ Broken Bones ______________________________________________________ ___________________________________ Dislocations ______________________________________________________ ___________________________________ Surgeries ______________________________________________________ ___________________________________

MEDICATIONS ALLERGIES VITAMINS/HERBS/MINERALS _____________________________ ________________________ ______________________________________________________ _____________________________ ________________________ ______________________________________________________

Pharmacy Name ________________ ________________________ ______________________________________________________

Pharmacy Phone ________________ ________________________ ______________________________________________________

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:

Are you pregnant? Yes No Due Date ___________________________________