New Patient Health Inquiry

New Patient Health History Form

In order to provide you the best possible care, please complete this form and bring it to

your first appointment. All information is strictly CONFIDENTIAL.

Patient Data

First Name *

Last Name *

Date *

Email *

* Your email will NOT be shared with any 3d parties, and is used for occasional office announcements and promotions.

Patient Data

Street Address *

City *

State *

Country *

Postal Code *

Telephone (Work) *

Referred By *

Age *

Birth Date *

Social Security # *

Number of Children *

Occupation *

Employer *

Marital Status *

Spouse's Occupation *

Spouse's Name *

Spouse's Employer *

Spouse's Health Status *

Emergency Contact *

Phone number *

Current Complaints

Nature of Injury *

Automobile

Work

Other

Please describe the injury *

Date of Injury *

Date symptoms appeared *

Have you ever had same condition? *

Yes

No

If yes, when?

List of other practitioners seen for this injury/condition *

Have you ever been under chiropractic care? *

Yes

No

If yes, please describe

Insurance Information

Name of party responsible for payment *

Tel. *

Do you have health insurance? *

Yes

No

Name of company *

If an auto accident, please provide:

Insurance Company Name *

Contact Person *

Tel. Phone *

Claim # *

Signatures

Name of the insured *

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Patient’s signature and date *

Clear

Spouse’s or guardian’s signature and date *

Clear