WELCOMEone
Spouse's Name: _
Do you have kids? 0 Yes 0 No How many? _
ABOUT YOU
Today's Date: L- __ ~_ File #: _
Patient Name:_:-:-::=- -;:::-;::= -:-:;-LAST FIRST MI
What You Prefer To Be Called: 0 Male 0 Female
Birthdate: _---L-_--L/ __ Age:__ SS#: _
Mailing Address: _
STATE ZIPCITY
Home Phone #: _
Work Phone #:
Other Phone #s:
E-Mail Address: _
Referred By: _
Employer: __ ---,- How Long? _
Employer's Address: ---,-- _
Ext: _
STATE ZipCITY
Occupation: __
Status: 0 Minor0 SingleQ Married 0 Divorced0 Separated0 Widowed
twoCo. Name: _
Address: _
Phone#: _
Insured's SS#: _
Group # (Plan, Local, or Policy #): _
Insured's Name: .._. ~ _
Relation: Date of Birth: _~~'---_
Insured's Employer: --'--_Pleaseinformfront-desk of znc; Insurancesource.
INSURANCE INFO
REASON FOR VISIT
The reason for this visit is a result of (Please circle): work, sports, auto, trauma or chronic.
(Explain what happened): ~ _
Please describe the pain & its location: -,- _
When did condition begin? / /
Is this condition getting worse? 0 Yes 0 No D Constant D Comes and goes
Is this condition interfering with your (Please Circle): work, sleep, or daily routine,
If so, please explain: _
Have you had this or similar conditions in the past? 0 Yes r:J No
If so, please explain: ~----------
Have you been treated by a Medical Physician for this condition? DYes r:J NoIf so, where? _. ---- . _
Have you ever been treated by a Chiropractor before?
If so, whom? __ . . -_ Phone#: ~ _
DYes :JNo
DCI FORM #: OS-88 (F&B)
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Who should we contact? ~--------------.:.--
. Relation: ,------------------Home Phone #: Work Phone #: -,- _
Who is your Medical Doctor? Phone #: _
four IN f..VENT OF EMERGENCY
Do you: Take Supplements or Vitamins? DYes DNa / Exercise? OYes::J No
Are you ona special diet: 0 Yes 0 No / Since: __ /__ /__
Do you smoke? 0 No 0 Yes / How Much? How Long? _Are you wearing: 0 Heel Lifts 0 Sale lifts 0 Innersoles 0 Arch supports
. .
What is the age of your mattress? __ ls it comfortable? 0 Yes ONoFor women: Are you taking Birth Control? 0 Yes 0 NoAre you Pregnant? 0 No 0 Yes/How long? _._._ Nursing? 0 Yes 0 No
Hf..AL TH HISTORY
Are you taking any of the following medications?o Nerve pills 0 Pain killers (including aspirin) 0 Muscle relaxers ..0 Stimulantso Blood Thinners 0 Tranquilizers 0 Insulin 0 Other(s) --.------Do you have or ever had any of the following diseases or conditions?Y N Heart Attack / Stroke Y N Heart SurgJPacerilaker Y N Heart MurmurY N Congenital Heart Defect Y N Mitral Valve Prolapse Y N Artificial ValvesY N Alcohol/Drug Abuse Y N Venereal Disease Y N Hepatitis.Y N HIV+ / Aids Y N Shingles Y N CancerY N Frequent Neck Pain . Y N Emphysema / GlaucomaY N AnemiaY N High/Low Blood Pressure Y N Psychiatric Problems Y N Rheumatic FeverY N Severe/Frequent Headaches Y N Kidney Problems Y N Ulcers / ColitisY N Fainting/Seizures/Epilepsy Y N Sinus Problems Y N AsthmaY N Diabetes / Tuberculosis YN Difficulty Breathing Y N ChemotherapyY N Lower Back Problems Y N Artificial Bones / Joints Y N ArthritisPlease list any other serious medical conditionts) you have or ever had:
---"---.-.-~---~-------'--'----'-'.-.'-----
Please list anything that you may be .allergic to: _
List previous surgeries/treatments with dates: ._. ~-.-
------_._------------'---'----_._-_ ...-
List any past serious accidents with dates: _ .._... _
Family Health History: . ~----.~
.'
five
•SIXACCOUNT INFO
Person ultimately responsible for account
Name:_ ....._. .__. ...._... _
Relation:_---------_-
Billing Address:_~. __._. __ --~
CITY STATE ZIP
SSN:
D.L#: ----....:....---- ...---
Work Phone#: ~----Payment method: [] CASH o Check
_____ . .__ ._.._:1_[] Credit Card - Enter card # above (if accepted)
I hereby authorize assignment ofInitials my insurance rights and benefits
directly .to the provider for services ren-dered. I fully understand I am solely respon-sible for any balance not paid for by my
.' insurance company (if offered at this office).
• We invite you to discuss with us any questions regarding our services. The best health services are based on a friendly, mutualunderstanding between provider and patient.
• Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made withthe business manager. If.account is not paid within 90 days of the date of service and no financial arrangements have beenmade, you will be responsible for legal fees, collection agency fees, and any other expenses incurred in collecting your account.
• I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the providerand or managed care organization, to release. any information required to process insurance claims.
• I understand the above information and guarantee this form was completed correctly to the best of my.knowledge andunderstand it is my responsibility to inform this office of any changes to the information I have provided.
Signature Date _.-1_/__J Adult Patient '"....I Parent or Guardian .J Spouse
DCI FORM #: 05-88 (F&B)