Patient Demographics
Name:
*
First Name
Last Name
Birth Date:
*
-
Month
-
Day
Year
Date
Age:
*
Sex:
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Male
Female
Street Address
Street Address Line 2
City/ State
Postal/ Zipcode
Email:
*
example@example.com
Home Phone Number:
*
-
Area Code
Phone Number
Work Phone Number:
-
Area Code
Phone Number
Mobile Phone Number:
*
-
Area Code
Phone Number
Marital Status:
*
Single
Married
Do you have Insurance?
*
Yes
No
Social Security #:
Driver's License #:
Employer:
Occupation:
*
Spouse's Name:
Spouse's Employer:
Number of children and ages:
Name & Number of Emergency Contact:
*
Relationship:
*
Who can we thank for referring you to our office?
*
History of Complaint
Please identify the primary condition that brought you to this office:
*
On a scale of 0 to 10 with 10 being the worst and zero being no pain, rate your above primary complaint:
*
Please identify any secondary, third or fourth condition(s) that brought you to this office:
*
On a scale of 0 to 10 with 10 being the worst and zero being no pain, rate your above secondary complaint:
On a scale of 0 to 10 with 10 being the worst and zero being no pain, rate your above third complaint:
On a scale of 0 to 10 with 10 being the worst and zero being no pain, rate your above fourth complaint:
When did the problem(s) begin?
*
When is the problem at its worst?
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AM
PM
Mid-day
Late PM
How long does it last?
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It is constant
I experience it on and off during the day
It comes and goes throughout the week
How did the injury happen?
*
Condition(s) ever been treated by anyone in the past?
*
Yes
No
If yes, when and by whom?
How long were you under care and what were the results?
Name of previous Chiropractor:
*
What relieves your symptoms?
*
What makes your symptoms feel worse?
*
List any restricted activity you may be experiencing, due to your condition. How long can you currently do that activity with no pain? How long can you usually do that activity with no pain?
*
Is your problem the result of any type of accident?
*
Yes
No
Identify any other injury(s) to your spine, minor or major, that the doctor should know about:
*
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Past History
Have you suffered with any of this or a similar problem in the past?
*
Yes
No
If yes, how many times?
*
When was the last episode?
*
How did the injury happen?
*
Other forms of treatment tried?
*
Yes
No
If yes, please state what type of treatment and who provided it:
How long ago?
What were the results?
Please identify any and all types of jobs you have had in the past that have imposed any physical stress on you or your body:
*
If you have ever been diagnosed with any of the following conditions, please indicate below by checking the Past, Currenlty or Never circle:
*
Past
Currently
Never
Broken Bone
Dislocations
Tumors
Rhematoid Arthritis
Fracture
Disability
Cancer
Heart Attack
Osteo Arthritis
Diabetes
Cerebral Vascular
Other serious conditions
Please identify ALL PAST and any CURRENT conditions (injuries, surgeries, childhood diseases, adult diseases) you feel may be contributing to your present problem:
*
How long ago did you suffer from this condition(s) and what type of care did you recieve and by whom?
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Next
Social History
Smoking:
*
Cigars
Pipe
Cigarettes
I don't smoke
Please indicate below how often you participate in the following:
*
Daily
Weekends
Occasionally
Never
Smoking
Alcoholic Beverage Consumption
Recreational Drug Use
Do you participate in any hobbies or recreational activites? What does your exercise regime look like?
*
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Next
Family History
Does anyone in your family suffer with the same condition(s)?
*
Yes
No
I'm not sure
If yes, whom? Have they been treated for their condition?
Grandmother
Grandfather
Mother
Father
Sister(s)
Brother(s)
Son(s)
Daughter(s)
Treated
Untreated
Any other hereditary conditions the doctor should be aware of?
*
Yes
No
If you answered yes to the question above, please explain:
By signing below, I hereby authorize payment to be made directly to LaBelle chiropractic, for all benefits which may be payable under a healthcare plan or from any other collateral sources. I authorize utilization of this application or copies thereof for the purpose of processing claims and effecting payments, and further acknowledge that this assignment of benefits does not in any way relieve me of payment of liability and that I will remain financially responsible to LaBelle Chiropractic for any and all services I receive at this office.
*
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Today's Date:
*
-
Month
-
Day
Year
Date
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