Name _____________________________________ Social Security# ________________________________
Address __________________________________ City ___________________State ____ Zip ____________
Home Phone # ___________________ Work Phone # ____________________ Cell # ____________________
Email _______________________________________ Age _____ Birthdate _____________ Gender M F
Marital Status: M S W D # of Children ____ Referred By _________________________________
Name of Employer __________________________________________________________________________
Phone ________________________ Address ____________________________________________________
Family Health History - list whether living, age, and past or current health problems:
Mother___________________________________________________________________________________
Father____________________________________________________________________________________
Brothers__________________________________________________________________________________
Sisters___________________________________________________________________________________
Children__________________________________________________________________________________
Health Information:
Have you had previous chiropractic care? If so, when was the last visit? ________________________________
Name and address/phone # of Chiropractic Office? _________________________________________________
What is your major complaint? _________________________________________________________________
What caused your complaints: car accident work injury other __________________________________
Have you had this or similar conditions in the past? _________________________________________________
Other current complaints: _____________________________________________________________________
Date current complaints/conditions began: ________________________________________________________
Is this condition getting progressively worse? Yes No Constant Comes and Goes
Is this condition interferring with your: Work Sleep Daily Route Other ___________________________
What activities aggravate your condition? ________________________________________________________
________________________________________________________________________________________
Other doctors who have treated you (family, specialist, chiropractor), office location and phone #:
_________________________________________________________________________________________
_________________________________________________________________________________________
Date of last physical examination and by whom: ___________________________________________________
List surgical operations and year: _______________________________________________________________
_________________________________________________________________________________________
Drs. Initials ________ Patient Initials ________
Date _____________ Date ________________
Are you currently taking any medication or vitamin supplements? If yes, please list. _______________________
________________________________________________________________________________________
________________________________________________________________________________________
Are you wearing: Heel lifts Arch supports
Have you been in an auto accident: past year past 5 yrs over 5 yrs never
If yes, when, where and briefly describe accident ______________________________________________
Have you had any other personal or job related injuries or accidents? past year past 5 yrs over 5 yrs never
If yes, briefly describe __________________________________________________________________
On the Diagram, please indicate all areas of:
Pain - XXX
Stiffness - \ \ \
Numbness - OOO
Other (specify) - ____________
Also rate your symptoms using this pain scale
0-1-2-3-4-5 (5 being most severe)
Insurance Information
** Is your condition due to an auto accident? If yes, when and where did the accident occur? ________________
_______________________________________________________________________________________
Name and address of Auto Insurance Company __________________________________________________
Phone # _____________________________ Claim # __________________________________
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**Is your condition related to a work injury? If yes, when and where did the injury occur? __________________
_______________________________________________________________________________________
Name and address of employer _____________________________________ Phone # __________________
Name of Workers Compensation Insurer _______________________________ Phone # _________________
Claim # __________________________
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Health Insurance Info-Name of Carrier ______________________ Policy # _____________ Group # _______
Name of Subscriber ________________________________ Date of Birth __________ SSN _______________
Name and address of employer ________________________________________________________________
I hereby direct ______________________ to pay by check made out and mailed directly to Thomas D. Barnes,
(name of insurance company)
at the above address. My signature below is a direct assignment of my rights and benefits under this policy. I also authorize the release of any information pertinent to my case to any Insurace company, adjustor, or attorney involved in this case.
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ALL PATIENTS:
Payment is expected at the time services are rendered. Keep in mind that the financial obligation for chiropractic treatment is between you and our office and is not dependent upon insurance coverage. We will provide you with receipts with pertinent information for you to be reimbursed by your insurance company.
We are participating providers for First Health Network, BCBS HMO, PPO, POS products and will complete and file all insurance claims for you, after we have verified your insurance benefits and you have met your obligations for your policy (i.e. referrals, precertifications,copays).
We are NOT participating with MEDICARE, however, we will file the necessary forms and payment will be mailed to you.
As a patient of this office you aggree to keep all your appointments. If for some reason you need to reschedule your appointment please contact our office within 24 hours or a $40 charge will be applied to your account which is not covered by insurance. Please reschedule all missed appointments within 7 days in compliance with your care-plan.
This office accepts cash, check, Visa, Mastercard and Discover. Any checks returned for insufficient funds will be charged a $30.00 fee. Any unpaid unresolved balances will be forwarded to our collections agency after 30 days.
Patient's Signature: ____________________________________________ Date __________
