Chiropratic Online Registration
About You
Name File #
What You Prefer To Be Called Male  Female
Birthdate Age
SS# Address
Home Phone
Other Phone Referred By
Employer How Long?
Occupation Employer’s Address
Work Phone
Marital Status Single      Married      Divorced      Widowed
Spouse’s Name Spouse’s Work Phone
Medical Physician’s Name
INSURANCE INFO
Co. Name Address
Phone# Insured’s SS#
Group#(Plan, Local
or Policy #)		 Insured’s Name
Relationship Date of Birth
Insured’s Employer
Please inform front desk of second insurance source
REASON FOR VISIT
Have you had previous chiropractic care?
What is your major complaint?
Other Complaints
How did condition develop?
Date of onset Have you had same or similar problems in the past? Yes      No     
Is this condition getting worse? Yes      No      Constant      Comes & goes
How long has it been since your really felt good? What aggravates condition?
Does anything offer relief?
How would you describe discomfort? Sharp      Dull      Achey      Throbbing
What percent of time does this condition bother you? 0%      25%     50%      75%      100%
How would you rate the level of discomfort on a scale of 0-10 (0=no pain 10=extreme pain)? Others who have treated you for this condition
HEALTH HISTORY
Are you taking any of the following medications?
Nerve pills   Pain killers (including aspirin)Muscle relaxers Stimulants Blood thinners Tranquilizers Insulin
Other(S)
Heart Attack / Stroke Yes   No Heart Surg./ Pacemaker Yes   No Heart Murmur Yes   No
Congenital Heart Defect Yes   No Mitral Valve Prolapse Yes   No Artificial Valves Yes   No
Alcohol / drug Abuse Yes   No Venereal Disease Yes   No Hepatitis Yes   No
HIV+ / AIDS Yes   No Shingles Yes   No Cancer Yes   No
Frequent Neck Pain Yes   No Emphytsema/ Glaucoma Yes   No Anemia Yes   No
High/Low Blood Pressure Yes   No Psychiatric Problems Yes   No Rheumatic Fever Yes   No
Severe/ Frequent Headaches Yes   No kidney Problems Yes   No Ulcers / Colitis Yes   No
Fainting/ Seizures/ Epilepsy Yes   No Sinus Problems Yes   No Asthama Yes   No
Diabetes / Tuberculosis Yes   No Difficulty Breathing Yes   No Chemotherapy Yes   No
Lower Back Pain Yes   No Artificial Bones/ Joints Yes   No Arthritis Yes   No
Please list any other serious medical condition(s) you have or ever had
Please list anything that you may be allergic to
List all previous surgeries/treatments with dates
List any and all accidents with dates
Do you exercise regularly No   Yes How much? How long?
Do you smoke? No   Yes How much? How long?
Are you wearing Heel lifts      Sole lifts      Inner soles      Arch supports
What is the age of your mattress? Is it comfortable? Yes     No     
For Women
Are you taking birth control? Yes     No     
Are you preganant? No  Yes How long? Nursing? Yes     No     
ACCOUNT INFO
Person ultimately responsible for account
Name  
Relation  
Billing Address
S.S. #  
D.L. #  
Work Phone#  
Payment method Cash      Check      Credit Card     
CC# (if accepted)  
   I hereby authorize assignment of my insurance e rights and benefits directly to the provider for services rendered
    (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, mutual understanding 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 with the business manager. If account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for any expenses incurred in collecting your account.
  • I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider 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 and understand it is my responsibility to inform this office of any changes in my medical status.