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File # 
Gender
Date of Birth (Filled out in office)
Social Security # (Filled out in office)
Status
Do you have Children?
Primary Insurance
Insured's SS# (Filled out in office)
Date of Birth (Filled out in office)
Secondary Insurance
Insured's SS# (Filled out in office)
Date of Birth (Filled out in office)

Account Information 

Person ultimately responsible for account
Social Security # (Filled out in office)
Payment Method
Credit Card # (Filled out in office)
Exp.
Consent

In Event of Emergency 

Reason for Visit

Reason for today's visit
Are you in pain?
Rate your pain with the following scale
Discomfort
Intense
Did your injury occur during?
Is your condition getting worse?
Is your condition interfering with your (you may select more than one)
Has this or something similar happened in the past?
Using the adjacent body charts, please circle all affected areas
Chiropractic bodt chart
Have you been treated by a Medical Physician for this condition?
Have you been treated by a Chiropractor?

Health History

Are you taking any of the following medications?
Do you have or have you had any of the following diseases, medical conditions or procedures?
Do you take Supplements or Vitamins?
Do you exercise?
Do you smoke?
Are you wearing
Are you dieting?
For Women
Are you takng Birth Control?
Are you Pregnant?
Are you Nursing?

About You

Insurance Infomation

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