Fidi-chiro - Chiropractic Registration and History

Chiropractic Registration and History
Patient Information
Date

MonthDayYear
Date
SS / HIC / Patient ID #
Patient Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Sex

MF
Age
Birthdate

MonthDayYear
Date
Marital Status

MarriedSeparatedWidowedDivorcedSingleMinorPartnered (for how many years?)
Patient Employer / School
Occupation
Employer/School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer/School Phone
Please enter a valid phone number.
Spouse's Name

First NameLast Name
Birthdate

MonthDayYear
Date
SS#
Spouse's Employer
Whom may we thank for referring you?
Insurance Information
Who is responsible for this account?

First NameLast Name
Relationship to Patient
Insurance Company
Group #
Is patient covered by additional insurance?

YesNo
Subscriber's Name

First NameLast Name
Birthdate

MonthDayYear
Date
SS#
Relationship to Patient
Insurance Company
Group #
ASSIGNMENT AND RELEASE
I certify that I and/or my dependent(s), have insurance coverage with Name of Insurance Company(ies) and assign directly to Dr. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
Signature of Patient, Parent, Guardian or Personal Representative

Clear
Please print name of Patient, Parent, Guardian or Personal Representative

First NameLast Name
Date

MonthDayYear
Date
Relationship to Patient
Phone Numbers
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Best time and place to reach you
IN CASE OF EMERGENCY, CONTACT
Name

First NameLast Name
Relationship
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Accident Information
Is condition due to an accident?

YesNo
Date

MonthDayYear
Date
Type of accident

AutoWorkHomeOther
To whom have you made a report of your accident?

Auto InsuranceEmployerWorker Comp.Other
Attorney Name (if applicable)
Patient Condition
Reason for Visit
When did your symptoms appear?
Is this condition getting progressively worse?

YesNoUnknown
Mark an X on the picture where you continue to have pain, numbness, or tingling
Rate the severity of your pain from 1 (least pain) to 10 (severe pain)
Type of pain:

SharpBurningDullTinglingThrobbingCrampsNumbnessStiffnessAchingSwellingShootingOther
How often do you have this pain?
Is it constant or does it come and go?
Does it interfere with your

WorkSleepDaily RoutineRecreation
Activities or movements that are painful to perform

SittingStandingWalkingBendingLying Down
Health History
What treatment have you already received for your condition?

MedicationsSurgeryPhysical TherapyChiropractic ServicesNoneOther
Name and address of other doctor(s) who have treated you for your condition

	Date
Physical Exam
Spinal Exam
Dental X-Ray
Spinal X-Ray
Chest X-Ray
MRI, CT-Scan, Bone Scan
Blood Test
Urine Test

Place a mark on "Yes" or "No" to indicate if you have had any of the following:

	Yes	No
AIDS/HV
Alcoholism
Allergy Shots
Anemia
Anorexia
Appendicitis
Arthritis
Asthma
Bleeding Disorders
Breast Lump
Bronchitis
Bulimia
Cancer
Cataracts
Chemical Dependency
Chicken Pox
Diabetes
Emphysema
Epilepsy
Fractures
Glaucoma
Goiter
Gonorrhea
Gout
Heart Disease
Hepatitis
Hernia
Herniated Disk
Herpes
High Blood Pressure
High Cholesterol
Kidney Disease
Liver Disease
Measles
Migraine Headaches
Miscarriage
Mononucleousis
MultipleSclerosis
Mumps
Osteoporosis
Pacemaker
Parkinson's Disease
Pinched Nerve
Pneumonia
Polio
Prostate Problem
Prosthesis
Psychiatric Care
Rheumatoid Arthritis
Rheumatic Fever
Scarlet Fever
Sexually Transmitted Disease
Stroke
Suicide Attempt
Thyroid Problems
Tonsilitis
Tuberculosis
Tumors, Growths
Typhoid Fever
Ulces
Vaginal Infections
Whooping Cough

If other, explain
Exercise

NoneModerateDailyHeavy
Work Activity

SittingStandingLight LaborHeavy Labor
Habits

SmokingAlcoholCoffee / Caffeine DrinksHigh Stress Level
Packs/Day
Drinks/Week
Cups/Day
Reason
Are you pregnant?

YesNo
Due Date

MonthDayYear
Date

Injuries/Surgeries you have had

	Description	Date
Falls
Head Injuries
Broken Bones
Dislocations
Surgeries

Medications
List of all medications
Pharmacy Name
Pharmacy Phone
Please enter a valid phone number.
Allergies
Vitamins / Herbs / Minerals
Should be Empty:

Chiropractic Registration and History

Patient Information

Insurance Information

Phone Numbers

Accident Information

Patient Condition

Health History

Medications