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 and BLACK ink  . If you have any questions or concerns, do not hesitate to ask for assistance. We will be happy to help.

(Please Print)
Name______________ Date_______________ Patient No._______  S/S_______________

First______________________ MI____________ Last_____________

Address_______________________ City_______________ State_______ Zip _________  

 Sex: __Female  __ Male Birth date_________ Home phone #____________________

Work phone #___________________   Do you prefer to receive calls at: Home ___ Work___ 

Are you:__ A Minor ___ Married __Divorced __  Partnered ___ Widowed ___Single ___Separated

Your employer__________________________ Occupation__________________________

Business Address______________________ City_______________ State_____  Zip_______

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 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? ___Yes  ___ No

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?______________

Insurance Information 

Name of insured______________________________ Relationship to Patient _________________________

Birth date______________________ Social Security # ______________________ 

Date Employed _________  Name of employer _______________________________ 

Work phone #____________________________

Address_________________________________ City __________________ State ______  Zip __________

Insurance Co.________________________ Phone # _________________

Group # ________________   Employer #__________________

Insurance Co. Address__________________________ City________________ State____  Zip ______

How much is your deductible?____ How much have you used?______  Max. annual benefit?________

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 that the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependants.

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