Patient Registration s3

Chadron Chiropractic Clinic, PC

PATIENT REGISTRATION

Patient Name: ______Date of Birth: First Middle Initial Last Address:

City: ______State: ______Zip:

Sex: M/F Home Phone: ______Cell Phone:

Soc. Sec. No.: ______E-mail address:

Employer: ______Occupation: ______Work Phone:

Spouse/Emergency Contact: ______Soc. Sec. No.: ______Phone:

Person Responsible for Charges: ______Soc. Sec. No.: ______Phone:

Who can we release you health information to?______Phone:______

How will charges be taken care of today  CASH  CREDIT CARD  CHECK

***Who may we thank for referring you?

Primary Medical Doctor: ______Phone:

INSURANCE Insurance Company:______Policy No.:

Policy Holder’s Name:______ID#

Policy Holder’s Date of Birth:______Relationship to you:

Policy Holder’s Address (if different)______

Is this related to:  Auto Accident  Worker’s Compensation  Personal Injury  Other

CASE HISTORY PRESENT CONDITION:

Major complaint(s) and symptom(s):

Chadron Chiropractic Clinic, PC Page 1 When did this happen?

What were you doing?

Has the problem progressed? Y/N What do you do to make the problem feel better?

What makes your problem worse?

Has this happened before? Y/N If yes, how often?

Have you seen another doctor for this problem? Y/N Chiropractor/Medical

Name of Doctor: ______Type of Treatment:

Do you have any blood relatives with similar symptoms? Y/N Who?

HEALTH QUESTIONNAIRE

If you have ever had a listed condition in the past, please check it in the past column. If you are presently troubled by a particular condition, check it in the present column.

PAST PRESENT PAST PRESENT PAST PRESENT

 Neck pain   Rapid Heart Beat   Heart attack

  Shoulder pain   Chest pains   Aneurysm   Pain in arm/elbow   Heartburn/Indigestion   Angina   Hand pain   Excessive thirst   High blood pressure   Wrist   Abnormal weight loss   Stroke   Upper back pain   Abnormal weight gain   Asthma   Low back pain   Chronic cough   Cancer   Pain in lower leg/knee   General fatigue   Arthritis   Pain in upper leg/hip   Chronic sinusitis   Tumor   Pain in ankle or foot   Menstrual problems   Diabetes   Jaw pain   Endometriosis   Epilepsy   Swelling/stiffness of joints   PMS   Ulcer   Fainting   Kidney/bladder problems   HIV/AIDS   Visual disturbances   Abdominal pain   Blood disorder   Convulsions   Constipation   Liver disorder   Dizziness   Skin problems   Gallbladder problems

Chadron Chiropractic Clinic, PC Page 2   Headache   Depression   Colitis   Tinnitus (ear noises)   Difficulty swallowing   Bladder infection   Allergies   Numbness/Tingling   Weakness

Other Complaints:

Please list any past surgeries and hospitalizations:

Do you use tobacco products? Y/N If yes, how much/day?

Do you use alcohol products? Y/N If yes, how much/day?

Do you have any blood relatives with?

Cancer Y/N Who?

Hypertension Y/N Who?

Cardiovascular Y/N Who?

Diabetes Y/N Who?

Arthritis Y/N Who?

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and me. I authorize assignment of my insurance benefits (if applicable) directly to Chadron Chiropractic. I authorize Chadron Chiropractic to release and/or request records to or from other providers as necessary. I understand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will be immediately due and payable. An outstanding balance that is patient responsibility and is thirty days and older will be assessed a monthly service fee of $5.00 or interest charge of 21% APR depending on the amount of the balance. A 40% increase on the total balance will be added to all accounts that are turned over to full collection for non-payment. This policy is subject to change.

I hereby authorize the Doctor to examine and treat my condition as he deems appropriate through the use of Chiropractic Health Care, and I give authority for these procedures to be performed. I understand, as with any health care procedures, that there are certain complications, which may arise during chiropractic treatments. I do not expect the doctor to be able to anticipate all risks and complications, and I wish to rely upon the doctor to exercise judgment during the course of the procedure(s) which the doctor feels at the time, based upon the facts then known, that are in my best interest. It is understood and agreed the amount paid the Doctor for X-rays is for information from the x-rays only and the X-ray film will remain the property of this office, according to the laws of the United States Attorney General. I also agree that I am responsible for all bills incurred by me at this office. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis.

Patient’s Signature:______Date:

Guardians Signature Authorizing Care:______Date:

Chadron Chiropractic Clinic, PC Page 3 On the figure below please use the following letters to indicate TYPE and LOCATION of the symptoms you currently are experiencing.

A=Ache B=Burning P=Pins & Needles N=Numbness S=Stabbing

Chadron Chiropractic Clinic, PC Page 4 Rate your pain Least 1 2 3 4 5 6 7 8 9 10 Severe

Chadron Chiropractic Clinic, PC Page 5