OBERHEIDE CHIROPRACTIC

CHIROPRACTIC REGISTRATION AND HEALTH HISTORY FORM

PATIENT INFORMATION INSURANCE INFORMATION Patient Name:______Who is responsible for this account? Date:______Social security #:______SS# of insured ______Address:______Birthdate of insured______Relationship to patient ______E-mail:______Insurance Co. ______Birthdate:______Group #______Policy # ______( ) Married ( ) Single ( ) Divorced Assignment and release: ( ) Widowed ( ) Minor I certify that I, and/or my dependents, have insurance coverage with ______and assign directly to Dr. ( ) Partnered for ____ years Oberheide all insurance benefits, if any, otherwise Employer/school______payable to me for services rendered. I understand that I Employer address______am financially responsible for all charges whether or not paid by insurance. I authorize the use for my signature on ______all insurance submissions. Employer phone #______The above named doctor may use my health care Spouse’s name:______information and may disclose such information to the above named insurance company and their agents for the Spouse’s employer:______purpose of obtaining payment for services and Whom may we thank for referring you? determining insurance benefits or the benefits payable for ______related services. This consent will end when my current treatment plan is completed. X______Date:______

PHONE NUMBERS ACCIDENT INFORMATION Cell ______Home______Is this condition due to an accident? Best time to reach you______( ) Yes ( ) No Emergency Contact: If yes, please complete personal injury form Name:______Number:______

PATIENT CONDITION Reason for visit______When did your symptoms appear?______Is your condition getting worse over time?______Have you seen other doctors for this complaint?_____ Name:______Please rate the severity of your pain from 1-10 (10 is the worst pain)______Is it constant or does it come and go?______How often do you have this pain?______Does it interfere with your: ( ) work ( ) sleep ( ) daily routines ( ) recreation Activities which are painful: ( ) standing ( ) sitting ( ) lying down ( ) walking ( ) bending Type of pain: ( ) sharp ( ) dull ( ) throbbing ( ) numbness ( ) aching ( ) shooting ( ) burning ( ) tingling ( ) cramps ( ) stiffness ( ) swelling HEALTH HISTORY Date of last: Physical Exam______Spinal Exam______Spinal X-ray______Blood/Urine test______MRI/CT/bone scan______

Mark with an X to indicate if you have/had any of the following. Please also mark any that apply to immediate family, and indicate the relationship to you. AIDS/HIV ( ) Hepatitis ( ) Alcoholism ( ) Hernia ( ) Allergy Shots ( ) Herniated Disc ( ) Anemia ( ) High Cholesterol ( ) Anorexia ( ) Kidney disease ( ) Appendicitis ( ) Liver disease ( ) Arthritis ( ) Migraines ( ) Asthma ( ) Miscarriage ( ) Bleeding disorders ( ) Multiple Sclerosis ( ) Breast Lump ( ) Osteoporosis ( ) Bronchitis ( ) Pacemaker ( ) Bulimia ( ) Parkinsons ( ) Cancer ( ) Polio ( ) Cataracts ( ) Prostate problems ( ) Chemical dependency ( ) Prosthesis ( ) Diabetes ( ) Psychiatric Care ( ) Emphysema ( ) Stroke ( ) Epilepsy ( ) STD ( ) Fractures ( ) Suicide attempts ( ) Goiter ( ) Thyroid problem ( ) Gout ( ) Tonsillitis ( ) Heart Disease ( ) TB ( ) Tumors ( ) Ulcers ( ) Other ( ) Exercise: Work Habits: Other Habits: ( ) none ( ) sitting ( ) smoking quantity______( ) mild ( ) standing ( ) drinking quantity______( ) moderate ( ) light labor ( ) coffee/caffeine quantity______( ) heavy ( ) heavy labor ( ) stress reason______

Pregnancy history: # of pregnancies_____ # of live births______# of miscarriages_____ vaginal/C-section?______are you pregnant now?______If yes, due date?______Injuries/Surgeries- Please describe major injuries and any surgical procedures performed: ______MEDICATIONS ALLERGIES SUPPLEMENTS

Please list medications, what they are ______Please list supplements you are for, and how long you have been taking ______currently taking, where you purchased them: ______them, and the dose (if known): 1- ______1- ______2- ______2- ______3- ______3- ______4- 4-

5- 5-

PATIENT GOALS/EXPECTATIONS Please tell us what your goals/expectations of your care are- ( ) relief care- primary goal is to relieve your symptoms ( ) corrective care- complete the correction begun in the relief care ( ) stabilization- stabilize structures supporting the spine to prevent future episodes ( ) wellness- promotion of optimal functioning of all bodily systems ( ) other: ______

SHOW AREA(S) OF PAIN OR UNUSUAL FEELING Mark the areas on this body where you feel the described sensations. Use the appropriate symbols. Mark areas of radiation. Include all affected areas.

Numbness Pins & Needles Burning Aching Stabbing - - - - - 00000 xxxxx / / / / / - - - - - 00000 xxxxx / / / / / - - - - - 00000 xxxxx / / / / / Please mark on the pain scale from Zero to 10 the pain you feel with this condition. 10 being the worst pain you have felt with this condition. Pain Chart

Neck-Shoulder-Arm-Pain On a scale of zero to 10, I rate my discomfort as follows: (______) 0 10 no pain severe pain

Mid Back Pain On a scale of zero to 10, I rate my discomfort as follows: (______) 0 10 no pain severe pain

Low Back and Leg Pain On a scale of zero to 10, I rate my discomfort as follows: (______) 0 10 no pain severe pain right left left right