Welcome...We are glad you’re here!

Please describe your major complaint ________________________________________________________

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Was this problem due to _____ Auto accident — Date: _________________

_____ Work accident — Date: ________________

_____ Other

When noticed (if accident or injury please describe) ____________________________________________

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How does this interfere with normal living? __________________________________________________

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What activities make it worse? ____________________________________________________________

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Have you had treatment for same or similar condition? _________________________________________

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What have you done to treat this condition? __________________________________________________

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Please List: 1. Past Injuries ______________________________________________________________

2. Auto Accidents ___________________________________________________________

3. Major Illness (include year/type)______________________________________________

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4. Operations/Surgery (include year/type) ________________________________________

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5. Other doctors seen (and for what condition) _____________________________________

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Are you taking any medication (and for what)? ________________________________________________

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Any known Allergies to Medications?_______________________________________________________

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Do you some or use tobacco? ______________________________

Have you been diagnosed or treated for Hypertension (high blood pressure)? Yes: _____ No: _____

Previous chiropractic care (Dr. name and date of last visit)? ______________________________________

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Name ______________________________________________ Date ________________________________

Address _______________________________________ City____________ State ____ Zip _____________

Social Security Number _____________________________ Birth Date __________________ Age ________

Phone (home) ________________ (cell) _________________ Cell Phone Company _____________________ (to text reminders)

Primary Language Spoken: ________________ Race: _______ Ethnicity: Non-Hispanic: __ Hispanic: __ Other ___

Sex: M F Marital Status: M S W D Sep Email address ____________________________________________

Employer __________________________ Occupation ____________________ Work Phone ____________

Spouse Name ____________________________________ Number of Children _______________________

Who may we thank for referring you? __________________________________________________________

Name of your Medical Doctor ________________________________________________________________

Name of emergency contact person: ____________________________ Relation: ______________________

Address _________________________________________________ Phone __________________________

Employer _______________________________________________ Phone __________________________

It is your responsibility to notify us when you have a change in

your insurance information Insurance Information: Please present your insurance card to be copied for our records.

Supplemental Insurance ? _____________________________________________________________________

_____Personal Injury/Auto Accident Name/Address of Company __________________________________

Claim # _________________________ Adjuster’s Name ___________________________________

Is an attorney representing you in this case? Y N

Name of Attorney ___________________________________ Phone __________________________

_____Other name and Address of Company _____________________________________________________

ID &/or group # ____________________________________________________________________

I certify that the above information is true and correct. I hereby authorize the release of any information required. I also author-

ize my benefit payments to be paid directly to this office. I am financially responsible for non-covered services. If accepted as a

patient at Patrick Chiropractic, I authorize any treatment which may be necessary. Any risks regarding Chiropractic Care will be

explained upon my request.

Fees are due at the time service is rendered.

I plan to pay be: _________ Cash ___________ Check ______________ Credit/Debit Card

Date ______________________________ Patient/Guardian Signature _______________________________