Natural Life Chiropractic Patient Information Form

Patient Information:

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Thank you for choosing our practice for your chiropractic needs. Please be sure to complete this form in full and use
BLACK ink. If you have any questions or concerns, do not hesitate to ask for assistance. We will be happy to help.

(Please Print)
Date_______________ 

First___________________________________________ MI___  Last___________________________________________

Address__________________________________________________ City_______________ State_______ Zip _________  

 Sex: Female __  Male __ Birth date:___/____/___ Home phone:____________________  

Cell Phone:___________________   Work phone #___________________   

We give reminder calls. Would you prefer to receive calls at: Home ___ Work___  Cell___

Are you:  A Minor ___   | Married __  | Divorced __ | Partnered ___  | Widowed ___ | Single___ |  Separated___

Your employer__________________________ Occupation__________________________

Spouse's or parent's name__________________________ Workplace_____________   Work phone #_______

Who do we thank for referring you to us? ______________________________ 

Person to contact in case of emergency____________________________ 

Phone # _______________  

Responsible Party

Person responsible for this account? ___________________________  Relationship to patient______________________

Phone # __________________________

Address_________________________________________ City______________ State ________ Zip _______

Name of employer ________________________________ Work Phone # _____________________

Symptoms

Reason for visit _______________________________________________________________________________________  

When did you first notice the symptoms?__________________________________________________________________

Is this condition getting progressively worse? Yes: _____ No: ____ The Same:____

Where specifically is the problem(s) located_____________________________________________________________________

Which activities are difficult to perform?  Sitting:___ Standing: ___ Walking: ___  Bending:___ Lying Down: __________

Type of pain: Sharp ____ Dull ____ Throbbing ___ Numbness ___ Aching ___ Shooting____ Burning ___ Tingling ______

Cramps___ Stiffness ___ Swelling ___ Other _________________________________________________________

Rate the severity of your pain. (l, mild pain or discomfort, to 10, severe pain Circle Choice):  1  2  3  4  5  6  7  8  9 10

Is the pain constant or does it come and go? _________________________________________________

What treatment have you already received for your condition? Other Chiropractor_____  Medication ________ Surgery______ 

Physical Therapy ________    Other______________

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

_____________________________________________________________________

Health History

Check only those conditions which are applicable:

Dates of last exams:___________________________________________________________________________________  

(Women) Are you pregnant?  Yes ___ No ___  Nursing?  Yes ___  No ___  Taking birth control pills?_________  

List any types of surgeries which you have and the dates which they occurred: _________________________________________________________________________________________________

_________________________________________________________________________________________________

Please list all medications you are currently taking: ______________________________________________________

Allergies:_________________________________________________________________________________________

Daily Habits

What type of exercise do you perform on a daily basis ?( Circle Answer)  None        Moderate        Heavy

What do your daily work habits include? (ex: sitting, standing, light labor, heavy labor, computer work) __________________________________________________________________

What vitamins do you currently take ? ___________________________________

What kind of other nutritional supplements do you take (if any):  ____________________________________________________________________

Do you smoke? ___ No ___ Yes          How much per day? _______________

How much liquor do you consume on a weekly basis? _____________________

How much coffee or caffeinated beverages do you consume on a daily basis?______________


Authorization
I certify that I have read and understand the above information to the best of my knowledge The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the chiropractor to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such chiropractic care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the chiropractor or chiropractic group insurance benefits otherwise payable to me. I understand that my chiropractic insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

 X______________________________ Date___________________________________ 
SIGNATURE OF PATIENT (or parent if a minor)