1. Major Surgery/Operations: _____Appendectomy _____Hernia _____Tonsillectomy _____Gall Bladder _____Back Surgery _____Broken Bones _____Other:___________________________________ Chiropractic Health Group Confidential Patient Information Date:_____________ Personal History Name:________________________________________ Address:______________________________________ City:___________________ St:______ Zip:_________ Home Phone:______________ Birthdate:___/___/____ Sex: M F Age:_____Cell Phone:________________ Height _____ft _______in Weight _________lbs Driver’s Lic #:_________________________________ Occupation:___________________________________ Social Sec#:___________________________________ Employer Name:_______________________________ Referred By:___________________________________ Have you ever been under Chiropractic Care? Y N Purpose of this Appointment:_____________________ Doctor’s Name and Phone Number: ________________ _____________________________________________ Have you ever had the same or similar condition? Y N Date Symptoms Appeared:____/_____/________ What aggravates the condition:____________________ If yes, when:___________________________________ What do you believe is wrong with you:_____________ _____________________________________________ What makes it better:____________________________ If yes, Name & Address of Dr:____________________ _____________________________________________ Have you seen another doctor for this condition: Y N What medications or drugs are you taking?___________ _____________________________________________ What type of treatment did you receive?______________________________________ _____________________________________________ Is your condition due to an automobile accident: Y N Is your condition due to your employment: Y N Have you lost time from work: Y N Is it ( ) Constant ( ) Comes & Goes Other__________ Is this condition getting progressively worse: Y N Is this condition interfering with: ( ) Work ( ) Sleep ( ) Daily Routine ( ) Other:_____________________ Describe in detail:______________________________ _____________________________________________ Do you notice any activity restrictions as a result: Y N Do you suffer from any condition other than that which you are now consulting us: Y N Please Describe: _____________________________________________ _____________________________________________ Major Accident or Falls:_________________________ _____________________________________________ Drugs you now take: ____ Nerve Pills _____ Insulin _____ Pain Killers/Muscle Relaxants _____ Blood Pressure Meds _____ Other:_____________________ _____________________________________________ Current Health Condition Insurance Past Medical History Hospitalization (other than above:__________________ _____________________________________________ Medical Dr’s Name & Phone#:____________________ _____________________________________________ Who is responsible for your bill? You and : ( )Spouse ( )Workers’ Comp ( ) Auto Ins ( ) Medicare ( ) Medicaid ( ) Health Ins ( ) No Coverage ( ) Other_____________________________________ If you have an insurance care (or cards) we can photocopy them and you can skip to the next section. Health Insurance: Insured Name: _________________________________ Birthdate:___/___/_____ SS#:_____________________ Policy #:_____________________ Group #:_________ Insured Co:__________________ Phone #__________ Address:______________________________________ Adjuster:______________________________________ Insured Name: _________________________________ Birthdate:___/___/_____ SS#:_____________________ Policy #:_____________________ Group #:_________ Insured Co:__________________ Phone #__________ Address:______________________________________ Adjuster:______________________________________ Secondary Health Insurance: E-Mail:______________________________________

2. Below is a list of diseases which may seem unrelated to the purpose of your appointment. However, these questions must be answered carefully as these problems can affect your overall course of chiropractic care. CHECK ANY OF THE FOLLOWING DESEASES YOU HAVE HAD:  Pneumonia  Rheumatic Fever  Tuberculosis  Whooping Cough  Mental Disorders  Heart Disease  Anemia  Measles  Mumps  Small Pox  Chicken Pox  Diabetes  Cancer  Influenza  Pleurisy  Arthritis  Epilepsy  Eczema  Polio  Thyroid  Lumbago  Asthma  Hepatitis  Other CHECK ANY OF THE FOLLOING YOU HAVE HAD WITHIN THE LAST 6 MONTHS Musculo-Skeletal  Low Back Pain  Pain Between Shoulders  Neck Pain  Arm Pain R L  Leg Pain R L  Joint Pain/Stiffness  Walking Problems  Jaw Pain / Clicking  General Stiffness Nervous System  Nervous  Numbness  Paralysis  Dizziness  Forgetfulness  Confusion/Depression  Fainting  Convulsions  Cold/Tingling Extremities  Stress Genito-Urinary  Bladder Trouble  Painful/Excessive Urination  Discolored Urine Gastro-Intestinal  Poor/Excessive Appetite  Excessive Thirst  Frequent nausea  Vomiting  Diarrhea  Constipation  Hemorrhoids  Liver Problems  Gall Bladder Problems  Weight Trouble  Abdominal Cramps  Gas/Bloating  Heartburn  Black/Bloody Stool  Colitis Vascular  Stroke  Chest pain  Shortness of Breath  Irregular Heartbeat  Heart Problems  Blood Pressure  Lung / Congestion  Varicose Veins  Ankle Swelling EENT  Vision Problems  Dental Problems  Sore Throat  Ear Aches  Hearing Difficulty  Stuffed Nose General  Fatigue  Allergies  Loss of Sleep  Fever  Headaches Family History The following members have the same or similar problem as I do:  Mother  Father  Brother / Sister  Spouse  Child Male/Female  Menstrual Irregularity  Menstrual Cramps  Vaginal Pain/Infection  Breast Pain/Lumps  Prostrate Enlargement  Sexual Dysfunction  Other: ______________ _____________________ _____________________ _____________________ Females Only When was your last period?_______________ Are you Pregnant? Y N Not Sure I understand and agree that health and accident insurance policies are an agreement between an insurance carrier and myself. I acknowledge full responsibility for payment of services and agree to pay them in full at the time of service, unless other arrangements are made in advance. Furthermore, I understand that this chiropractic office will prepare any necessary reports and forms to assist me in making collections from the insurance company and that any amount authorized to be paid directly to this chiropractic office will be credited to my account on receipt. I also give this office power of attorney to endorse checks made out to me, to be credited to my account. However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will be immediately due and payable. In addition, I will pay all collection agency and/or attorney’s fees of 1/3 of the outstanding balance plus court costs, if my account is ever referred to same. The X-ray negatives will remain the property of this office, being on file where they may be seen at any time with a patient of this office. The Doctor will not be held responsible for any pre-existing medically diagnosed or undiagnosed conditions, nor for any medical diagnosis. Patient Signature:_____________________________________________________ Date:____________________ Guardian Signature Authorizing Care:_____________________________________ Date:____________________