WELCOMEone

Spouse's Name: _

Do you have kids? 0 Yes 0 No How many? _

ABOUT YOU

Today's Date: L- __ ~_ File #: _

Patient Name:_:-:-::=- -;:::-;::= -:-:;-LAST FIRST MI

What You Prefer To Be Called: 0 Male 0 Female

Birthdate: _---L-_--L/ __ Age:__ SS#: _

Mailing Address: _

STATE ZIPCITY

Home Phone #: _

Work Phone #:

Other Phone #s:

E-Mail Address: _

Referred By: _

Employer: __ ---,- How Long? _

Employer's Address: ---,-- _

Ext: _

STATE ZipCITY

Occupation: __

Status: 0 Minor0 SingleQ Married 0 Divorced0 Separated0 Widowed

twoCo. Name: _

Address: _

Phone#: _

Insured's SS#: _

Group # (Plan, Local, or Policy #): _

Insured's Name: .._. ~ _

Relation: Date of Birth: _~~'---_

Insured's Employer: --'--_Pleaseinformfront-desk of znc; Insurancesource.

INSURANCE INFO

REASON FOR VISIT

The reason for this visit is a result of (Please circle): work, sports, auto, trauma or chronic.

(Explain what happened): ~ _

Please describe the pain & its location: -,- _

When did condition begin? / /

Is this condition getting worse? 0 Yes 0 No D Constant D Comes and goes

Is this condition interfering with your (Please Circle): work, sleep, or daily routine,

If so, please explain: _

Have you had this or similar conditions in the past? 0 Yes r:J No

If so, please explain: ~----------

Have you been treated by a Medical Physician for this condition? DYes r:J NoIf so, where? _. ---- . _

Have you ever been treated by a Chiropractor before?

If so, whom? __ . . -_ Phone#: ~ _

DYes :JNo

DCI FORM #: OS-88 (F&B)

three

Who should we contact? ~--------------.:.--

. Relation: ,------------------Home Phone #: Work Phone #: -,- _

Who is your Medical Doctor? Phone #: _

four IN f..VENT OF EMERGENCY

Do you: Take Supplements or Vitamins? DYes DNa / Exercise? OYes::J No

Are you ona special diet: 0 Yes 0 No / Since: __ /__ /__

Do you smoke? 0 No 0 Yes / How Much? How Long? _Are you wearing: 0 Heel Lifts 0 Sale lifts 0 Innersoles 0 Arch supports

. .

What is the age of your mattress? __ ls it comfortable? 0 Yes ONoFor women: Are you taking Birth Control? 0 Yes 0 NoAre you Pregnant? 0 No 0 Yes/How long? _._._ Nursing? 0 Yes 0 No

Hf..AL TH HISTORY

Are you taking any of the following medications?o Nerve pills 0 Pain killers (including aspirin) 0 Muscle relaxers ..0 Stimulantso Blood Thinners 0 Tranquilizers 0 Insulin 0 Other(s) --.------Do you have or ever had any of the following diseases or conditions?Y N Heart Attack / Stroke Y N Heart SurgJPacerilaker Y N Heart MurmurY N Congenital Heart Defect Y N Mitral Valve Prolapse Y N Artificial ValvesY N Alcohol/Drug Abuse Y N Venereal Disease Y N Hepatitis.Y N HIV+ / Aids Y N Shingles Y N CancerY N Frequent Neck Pain . Y N Emphysema / GlaucomaY N AnemiaY N High/Low Blood Pressure Y N Psychiatric Problems Y N Rheumatic FeverY N Severe/Frequent Headaches Y N Kidney Problems Y N Ulcers / ColitisY N Fainting/Seizures/Epilepsy Y N Sinus Problems Y N AsthmaY N Diabetes / Tuberculosis YN Difficulty Breathing Y N ChemotherapyY N Lower Back Problems Y N Artificial Bones / Joints Y N ArthritisPlease list any other serious medical conditionts) you have or ever had:

---"---.-.-~---~-------'--'----'-'.-.'-----

Please list anything that you may be .allergic to: _

List previous surgeries/treatments with dates: ._. ~-.-

------_._------------'---'----_._-_ ...-

List any past serious accidents with dates: _ .._... _

Family Health History: . ~----.~

.'

five

•SIXACCOUNT INFO

Person ultimately responsible for account

Name:_ ....._. .__. ...._... _

Relation:_---------_-

Billing Address:_~. __._. __ --~

CITY STATE ZIP

SSN:

D.L#: ----....:....---- ...---

Work Phone#: ~----Payment method: [] CASH o Check

_____ . .__ ._.._:1_[] Credit Card - Enter card # above (if accepted)

I hereby authorize assignment ofInitials my insurance rights and benefits

directly .to the provider for services ren-dered. I fully understand I am solely respon-sible for any balance not paid for by my

.' insurance company (if offered at this office).

• We invite you to discuss with us any questions regarding our services. The best health services are based on a friendly, mutualunderstanding between provider and patient.

• Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made withthe business manager. If.account is not paid within 90 days of the date of service and no financial arrangements have beenmade, you will be responsible for legal fees, collection agency fees, and any other expenses incurred in collecting your account.

• I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the providerand or managed care organization, to release. any information required to process insurance claims.

• I understand the above information and guarantee this form was completed correctly to the best of my.knowledge andunderstand it is my responsibility to inform this office of any changes to the information I have provided.

Signature Date _.-1_/__J Adult Patient '"....I Parent or Guardian .J Spouse

DCI FORM #: 05-88 (F&B)