New Patient Health History Form

Patient Information

Contact Information

First name M.I. Last name *Email Birth Date Referred by Relationship

Mailing Address

Street Address City State Zip Phone (work) (home) (mobile) Occupation Employer Emergency Contact Phone Number

Family Information

Marital Status Spouse's Name Spouse's Occupation Spouse's employer Phone (work) (home) (mobile)

Health Information

Current Complaints

Nature of Injury 1 Automobile 2 Work 3 Recreation 4 Other Please describe compelling event and resulting injury. (500 chars left) Date of injury Date symptoms appeared Have you ever experienced the same condition? No Yes If so, when? Have you ever been under chiropractic care? No Yes If yes, please describe. (250 chars left)

Insurance Information

Name of Party Responsible for Payment Phone Do you have health care insurance? No Yes Name of Company

If an auto accident, please provide:

Insurance Company name Contact Person Phone Claim Number

Name of the injured

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Patient's signature

Date

Spouse or Guardian's signature

Date

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