New Patient Health History Form

1 Work Other Please describe ____________________________________________________________________________ ________________________________________________________________________________________ Date of injury ______________ Date symptoms appeared______________ Have you ever had same condition? No Yes If yes, when? ________________________________ List other practioners seen for this injury/condition ________________________________________________ Have you ever been under chiropractic care? No Yes If yes, please describe ______________________________________________________________________ Insurance Information Name of party responsible for payment __________________________ Phone ______________________ Do you have health insurance? No Yes Name of company ____________________________ * If an auto accident please provide: Insurance company name __________________________ Contact person ________________________ Phone ________________________________ Claim # __________________________________ Billing Address Name of the insured ________________________________________________________________________ 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 ser- vices rendered to me will be immediately due and payable. Patient’s signature______________________________________________ Date ____________________ Spouse’s or guardian’s signature __________________________________ Date ____________________ New Patient Health History Form In order to provide you the best possible wellnesscare, please complete this form andbring it to your first appointment. All information is strictly CONFIDENTIAL. Patient Data Name______________________________ Date ________ Email _____________________________ Mailing address Address ______________________________________________________ City ___________ State _____ Zip _______ Telephone (work) ____________ (home)__________ Referred By ________________________ Age______ Birth date __________ Social Security # ______________ Number of children______ Occupation ____________________________ Employer________________________________________ Marital Status __________ Spouse’s name________________ Spouse’s Occupation______________ Spouse’s employer ______________________ Spouse’s health status ____________________________ Emergency contact __________________________________________ Phone ______________________ Current Complaints Nature of injury: Automobile* Your email will NOT be shared with any 3d parties, and is used for general office announcements and promotions. Medical History Have you been treated for any conditions in the last year?