CHIROPRACTIC + ACUPUNCTURE + PHYSIOTHERAPY + MASSAGE

Dear Patient, please complete this questionnaire. Your answers will help us determine if you qualify for care in our clinic. Thank You!

PATIENT INFORMATION: Name_____________________________________________________ Gender M F Date_____________________ Birth Date_________________ Social Security # _________________ Height________ Weight_______ Marital Status S M D W Home Address_____________________________________________ City___________________________ State_____ Zip___________

Telephone (cell)__________________________ Email*_____________________________________ (*your email will NEVER be sold or shared) How would you like to receive appointment reminders? Email or Text Message: Who is your Cell phone carrier (i.e. t-mobile, AT&T, Verizon, Sprint, etc?:______________________ How soon before each visit should we send it? 30 minutes 1 Hour 3 Hours 1 Day Emergency Contact_______________________________ Relationship___________________ Phone_________________________ How did you hear about us? Referred by___________________ Google Yahoo Facebook Twitter Other_________________ What treatment are you interested in receiving at our office? Chiropractic Acupuncture/Dry Needling Massage Cupping Homeopathic Injections Whiplash Therapy Concussion/Neuro Therapy Scraping (Graston, ASTYM) Spinal Decompression Sports Med. Eval Physiotherapy Other:____________________

INSURANCE INFORMATION: Are you using insurance today? Y N Circle one: Auto or Health

Please provide: Insurance Company Name ___________________________________ Contact Person ______________________________________

Phone: ____________________________ Policy/Claim #___________________________ Date of Injury/Accident__________________

Please provide a copy of your insurance card to the secretary. Thank you.

**Please Note: Some insurances only pay for spinal adjustments and do not cover some of the other services we provide.

You are responsible for any deductibles, co-pays and non-covered charges.**

Reason For Visit:

What are your Treatment Goals?

Just get me out of pain, ONLY Get me out of pain, then go on to FIX THE CAUSE Fix me, then help me STAY FIXED LONG TERM

What are we treating today? Please include the Date it started and Grade it on a scale of 1 to 10.

Primary Complaint: Date it Started: (1=No complaint, 10=worst)

1)_________________________________________________ _____/_____/_____ 1 2 3 4 5 6 7 8 9 10

What makes your condition better?__________________________________ What makes it worse? ___________________________________

Is the condition interfering with your: Work Sleep Daily Routine Recreation Sports/Exercise Other_______________________ What type of pain do you feel? Dull/Achy Sharp Burning Tight Soreness Does the pain radiate or refer anywhere? Y N Have you received any treatment for this condition? Y N Have you experienced this complaint before? Y N

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Are there any other symptoms, besides the above, that you would like us to help you with? _________________________________________ _________________________________________________________________________________________

HEALTH HISTORY:

Have you ever had any surgeries? Please explain______________________________________________________________________________ Do you take any Medications or Supplements/Vitamins? Please explain_____________________________________________________________

Have you ever been diagnosed with any type of Hepatitis? Y N AIDS/HIV? Y N Strokes? Y N

Have you experienced any of these symptoms recently? Double Vision Difficulty Swallowing Difficulty Speaking Dizziness

Legs Give Out Suddenly Nausea Involuntary Rapid Eye Movements Numbness Impaired Balance/Coordination

Are there any current or past health conditions or anything else pertaining to YOUR HEALTH that you feel we should know about? Y N

If Yes, please explain:____________________________________________________________________________________________

Are there any current or past health conditions pertaining to your close FAMILY’s HEALTH that you feel we should know about? Y N

If Yes, please explain:____________________________________________________________________________________________

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Please return to the secretary, Thank you!