LACEY OFFICE   PINE BEACH OFFICE   SEAPORT OFFICE  

Confidential Patient Case History

Name___________________________________ Date____________________________

Home Phone #____________________________ Work Phone #____________________

Address__________________________________ City____________________________

State__________ Zip __________ D.O.B. _______________ Age__________________

M_______ F_______ Marital Status________________ Children____________________

S.S.#__________________________ Driver License #__________________ State______

Employer’s Name and Address________________________________________________

Emergency: Contact_________________________________________________________

Phone #____________________________________ Relationship____________________

Spouses Employer and Address________________________________________________

Health Insurance Primary Carrier______________________________ID#______________

Spouses D. O. B.___________________ Secondary Ins.___________ID#______________

Major Complaint _____________________________________________________

___________________________________________________________________

Other Complaint______________________________________________________________

______________________________________________________________________________

What Improves Your Condition________________________________________________

______________________________________________________________________________

What Worsens Your Condition_________________________________________________

______________________________________________________________________________

Primary Care

Physician___________________________________________________________

Have you had any medical care for this condition?______ If so, what

type?__________________

__________________________Results______________________________________________

Is/Does Your Condition (Circle) Deteriorating Constant Comes and Goes Interfere

with: Sleep Your work Daily Routine

Other______________________________________Have you had some/similar symptoms in

the past?__________Explain______________________________________________________

Is there a family history of this condition_____Have you had previous chiropractic

care________

If so where____________________________________________________________________

How did you hear of us___________________________________________________________

List previous surgeries and

dates____________________________________________________

______________________________________________________________________________

Medications currently

taking_______________________________________________________

______________________________________________________________________________

Do you take birth control pills__________________________What

Type___________________

Are you HIV positive____________________________Breast implants____________________

Do you have an IUD_______________Do you have Norplant____________________________

Person responsible for this

account__________________________________________________ Please check the appropriate space for any of the following symptoms which you now have or have had

previously. We need all the facts about your health before we can accept your case.

THIS IS A CONFIDENTIAL REPORT.

__Arthritis __Gallbladder Trouble

__Bursitis __Hemorrhoids

__Foot Trouble __Pain over Stomach

__Hernia __Excessive Menstrual Flow

__Low Back Pain __Sore Throat

__Neck Pain/Stiffness __Asthma

__Pain between shoulders __High Blood Pressure

__Headache __Low Blood Pressure

__Loss of Sleep __Kidney Infection/Stone

__Sciatica __Painful Menstruation

__Spinal Curvature __Vaginal Discharge

__Swollen Joints __Cramps/Backache

__Allergy __Sinus Infection

__Fatigue __Hot Flashes

__Dizziness __Irregular Cycle

__Loss of Weight __Painful Urination

__Nervousness/Depression __Prostate Trouble

__Constipation __Diarrhea

Pain or Numbness in:

__Shoulders __Arms __Hands __Hips

__Legs __Knees __Feet

Check the following conditions you have had:

__Alcoholism __Diphtheria __Influenza __Pneumonia

__Anemia __Eczema __Lumbago __Polio

__Appendicitis __Emphysema __Lyme Disease __Rheumatic Fever

__Arteriosclerosis __Epilepsy __Malaria __Scarlet Fever

__Arthritis __Fever Blisters __Measles __Stroke

__Cancer __Goiter __Miscarriage __Tuberculosis

__Chorea __Gout __Multiple sclerosis __Typhoid Fever

__Cold Sores __Heart Disease __Mumps __Ulcers

__Diabetes __Hepatitis __Pleurisy __Venereal Disease

__Other (explain)________________________________________________________

Date: X-rays________Blood Test_______Urinalysis________Spinal Tap________

NOTICE TO OUR NEW PATIENTS

CHIROPRACTIC SERVICES PROVIDED IN THIS OFFICE ARE PAYABLE THE DAY SERVICES ARE

RENDERED UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE PRIOR WITH THE DOCTOR.

INSURANCE CASES

1. Assignments of insurance benefits will be accepted upon proper verification of coverage and at the :p>

discretion of this office.

2. Patients are personally responsible for all charges.

3. We will prepare necessary reports to help collect your benefits if an assignment is not taken.

4. By signing below you give us the authority to bill your insurance company directly.

Patient’s Signature_____________________________

Insured’s Signature________________________________