Tice Valley Chiropractic - Patient Intake-Registration

REGISTRATION
Date:

MonthDayYear
Date
Phone:
Please enter a valid phone number.
Patient:

First NameLast NameInitial
Street Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sex:

MaleFemale
Age:
Birthdate:

MonthDayYear
Date
Marital Status:

SingleMarriedWidowedDivorcedSeparated
Social Security #:
Email:
example@example.com
Insured’s Name:

First NameLast NameInitial
Patient Agreement:

ASSIGNMENT AND RELEASE

I irrevocably authorize and assign to you, the chiropractic provider, the right to receive direct payment from my attorney or any Insurance company which may become obligated to pay me any sums. The Patient(s) grant(s) to the Provider a Limited Power of Attorney to receive funds, negotiate any drafts or checks and execute any documents related to payment for services rendered to me
Signature of Insured/Guardian

Clear
Date:

MonthDayYear
Date
Present Complaints (Please check the appropriate ones)
HeadacheFeet/Hands ColdUnbalancedMental dullnessDepressionFaintingLoss of memoryRib painBlurred visionDizzyNervousnessIrritabilityEars ringing/buzzingEye strain/painDouble visionUpper back painShortness of breathLoss of smellLower back painFearChest painMidback painConfusionNeck painPins and needles in hands right/leftPins and needles in arms right/leftPins and needles in legs right/left
Medical Implants:
Medical Alerts:
Surgical Implants:
Pregnancy:

YesNo
PAIN SCALE: Rate the severity of your pain by checking a box on the following scale.

0

1

2

3

4

5

6

7

8

9

10

0 is No Pain, 10 is Excruciating Pain
Medications: (please list all medications and supplements that you currently take)
Allergies: (please list all medications that cause allergic reaction)
Smoking:

YesNo
If yes, Packs per day for__years.
Alcohol:

YesNo
If yes, Number of drinks per week
Surgical History: Please list ALL previous surgery and the date on which it was performed:
Personal Medical History & Review of Systems:

Please check the below any medical problems that you currently have or have had in the past.
NO MEDICAL PROBLEMS - no prior history of any significant medical problems
Lungs / Pulmonary – breathing disorders

asthmapulmonary embolismrespiratory arrestCOPDpneumoniasleep apneaemphysematuberculosisOther:
Cardiac / Heart and peripheral vascular disease

chest pain / anginahigh blood pressureirregular heartbeat, arrhythmiaheart attackheart murmur, valve disorderperipheral vascular diseasecongestive heart failuremitral valve prolapsedeep vein thrombosisbleeding problemsOther:
Neurologic Disorders

stroke or TIAParkinson’scerebral palsyperipheral neuropathyMSpolioOther:
Bone & Joint Disorders

osteoarthritisgoutosteomyelitisrheumatoid arthritislupusankylosing spondylitisOther:
Gastrointestinal Disorders

peptic ulcer or stomach ulcerdiverticulitishepatitisacid reflux, GERDirritable bowelliver diseaseGI bleedinflammatory bowel diseaseOther:
Hepatitis -Type
Genitourinary Disorders

urinary tract infectionkidney problemsdialysis, kidney failurebladder problemskidney stonesOther:
Metabolic & Other Disorders

Diabetesskin disorderdepressionthyroid problemspsoriasisanxietysickle cell diseaseany skin ulceralcohol or drug dependencyhigh cholesterol or lipidstooth abscess, gingivitisOther:
Diabetes-Years:
Skin Disorder:
Cancer : any type -- please specify
Other medical problems NOT included above (explain)
Family History:
Please indicate with an check mark any significant family medical history or problems.

asthmatuberculosissleep apneaCOPD or Emphysemaheart attack, myocardial infarctioncongestive heart failureirregular heartbeat, arrhythmiableeding problemsPeripheral neuropathyMS or Parkinson’sosteoarthritisLupusgoutrheumatoid arthritisacid reflux, GERDinflammatory bowel diseasehepatitisliver diseasekidney problemsdialysis, kidney failurediabetespsoriasishigh cholesterol or lipidsthyroid problemssickle cell diseaseany skin ulcerMalignant hyperthermia
Hepatitis-Type:
Other neuro:
Other lung:
Other bone & joint:
Other GI:
Cancer : any type -- please specify
Other medical problems NOT included above (explain)
PATIENT INSURANCE INFORMATION:
Please check any and all insurance coverage you or your spouse has applicable in this case.

MedicareBlue ShieldAuto AccidentMedicaidMajor MedicalUnion PlanBlue CrossWorker’s CompensationOther
Insurance Identification Number:
Medicare/Medicaid Identification Number:
Major Medical or Auto Insurance:
Date of Accident:

MonthDayYear
Date
Insurance Company Name:
Adjuster:
Address/Phone:
Claim #:
Policy #:
Effective Date:

MonthDayYear
Date
Primary Care Physician:
Name & Address:
Phone #:
Please enter a valid phone number.
LEGAL INFORMATION:
Attorney Name & Address:
Attorney Phone #:
*Person to contact in an emergency (Name and Phone #):
Patient Name:
Date:

MonthDayYear
Date
Should be Empty:

REGISTRATION

Family History:

PATIENT INSURANCE INFORMATION:

Major Medical or Auto Insurance:

Primary Care Physician:

LEGAL INFORMATION: