Office Forms

Mid County Chiropractic Registration & History Questionnaire

 

Last Name _____________________ MI _____________ First Name ___________________

What do you prefer to be called? ______________________

Home Address  __________________________ City ________________ State/Zip ________

Age ________________ Birth Date ________________(Circle One) M  F  Marital Status  S M W D O

 

Patients Social Security Number (required for billing) __________________________

Number of Children ________ Names & age of children _________________________________

Would you like to receive our e-mail newsletter? _____________________________

 

Patients Home Phone _________________  

Patients Work Phone__________________

Patients Cell Phone ___________________

Emergency Contact _____________________ Phone # __________________

Who is your Medical Dr? _________________ Phone #__________________

Who is your Medical Dr.? _________________Phone ___________________

 

Please Check One 

 ___Employed   ___Retired   ___Student   ___Other  __________________

Employer___________________________________

Occupation _________________________________

 

How did you hear about our office?

___Sign   ___Dr. ________   ___Patient ____________  

___Family ____________   ___Website

___Screening   ___Other __________________

 

Reason for Visit ___________________________________________________________________

When did your symptoms appear? _____________________________________________________

Is this condition getting progressively worse?  ___ Yes   ___ No   ___ Unknown

 

Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain) ________

Type of Pain:  ___Sharp   ___Dull   ____Throbbing   ___ Numbness   ___Burning   ___Tingling

___ Cramps   ___Stiffness   ___Aching   ___Swelling   ___ Shooting   ___Other

 

How often do you have this pain? _____________________________________________________

Is it constant or does it come and go? __________________________________________________

 

Does it interfere with your ___Work   ___ Sleep   ___Daily Routine   ___Recreation

Activities or movements that are painful to perform ___Sitting   ___Standing   ___Walking   ___Bending   ___Lying down

 

What treatment have you already received for your condition? ___Medication   ___Surgery   ___Physical Therapy   ___Chiropractic Services   ___None   ___Other_____________________

Name of Doctor(s) who have treated your condition _______________________________________

Date of last:  Physical Exam__________ Spinal X-ray__________ Blood Test __________  Spinal Exam__________ 

Chest X-ray __________ Urine Test _________

Bone  Density Test ________            MRI, CT-Scan ____________

 

Page 2

Place a check to indicate if you have had any of the following:

 

___AIDS/HIV               ___Chicken Pox      ___Liver Disease          ___Rheumatoid Arthritis

___Alcoholism               ___Diabetes      ___Measles                            ___Rheumatic Fever

___Allergy Shots           ___Emphysema   ___Migraine Headaches       ___Scarlet Fever

___Anemia                    ___Epilepsy       ___Miscarriage                      ___Stroke

___Anorexia                  ___Fractures     ___Mononucleosis                 ___Suicide Attempt

___Appendicitis ___Glaucoma    ___Multiple Sclerosis            ___Thyroid Problems

___Arthritis                   ___Goiter          ___Mumps                             ___Tonsillitis

___Asthma                    ___Gonorrhea   ___Osteoporosis                    ___Tumors, Growths

___Bleeding Disorders ___Gout             ___Pacemaker                       ___Ulcers

___Breast Lump           ___Heart Disease   ___Parkinson’s Disease        ___Vaginal Infections

___Bronchitis                ___Hepatitis      ___Pinched Nerve                  ___Sexually Transmitted Disease

___Bulimia                    ___Hernia          ___Pneumonia                        ___Whooping Cough

___Cancer                     ___Herniated Disc   ___Polio                                  ___Other __________________

___Cataracts                 ___Herpes         ___Prostate Problems               _____________________

___Chemical                  ___High Cholesterol   ___Prosthesis                            _____________________

___Dependency                        ___Kidney Disease  ___Psychiatric Care                  _____________________

 

Is condition due to an accident?  ___YES   ___NO  DATE:_______________________

Type of accident  ___AUTO   ___HOME   ___Other

To whom have you made a report of your accident?  ___Auto Insurance   ___Employer   ___Other

 

Work Activity

____Sitting   ___Standing   ___Light Labor   ___Heavy Lifting

 

Habits

___Smoking                      Packs/Day__________

___Alcohol                        Drinks/Week_______                                      

___Coffee/Caffeine Drinks      Cups/Day _________        

___High Stress Level               Reason _______________________________________

 

Injuries/Surgeries you have had             Description                                            Date

 

Falls                                                           __________________________________   _____________________

Head Injuries                                              __________________________________   _____________________

Broken Bones                                            __________________________________   _____________________

Dislocations                                                __________________________________   _____________________

Surgeries                                        __________________________________   _____________________

        Medication                     Allergies         Vitamins/Herbs/Supplements

____________________________          _____________________   _________________________________

____________________________          _____________________   _________________________________

____________________________          _____________________   _________________________________

____________________________          _____________________   _________________________________

 

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 to the information I have provided.

 

Patient Signature __________________________________________________  Date__________________________

                                           ___Adult Patient   ___Parent or Guardian   ___ Spouse

 

 

Mid County Chiropractic Insurance Information

 

Insurance Carriers Name                                  _______________________________________________________

Insured’s ID Number                                        _______________________________________________________

Insured’s Group #                                            _______________________________________________________

 

Are you the primary card holder? ___ Yes           ___No    If you answered “NO” complete the following

 

Please note all information below is required for insurance billing

 

Insured’s Name (Last, First, MI)            ____________________________________________________

Relationship to Patient               _________________________

Insured’s Date of Birth              _________________________

Insured’s Social Security Number            _________________________

Insured’s Employer                               _____________________________________

Insured’s ID Number                            _________________________

____Male   ___Female

Insured’s Mailing Address if different from patient’s address            ____________________________

                                                                                                              ____________________________

                                                                                                              ____________________________

Insured’s phone if different from patient’s phone number                 ____________________________

 

Additional Insurance (Secondary or Supplemental)

 

Insurance Carriers Name                                  _______________________________________________________

Insured’s ID Number                                        _______________________________________________________

Insured’s Group #                                            _______________________________________________________

 

Are you the primary card holder? ___ Yes           ___No    If you answered “NO” complete the following

 

Please note all information below is required for insurance billing

 

Insured’s Name (Last, First, MI)            ____________________________________________________

Relationship to Patient               _________________________

Insured’s Date of Birth              _________________________

Insured’s Social Security Number            _________________________

Insured’s Employer                               _____________________________________

Insured’s ID Number                            _________________________

____Male   ___Female

Insured’s Mailing Address if different from patient’s address            ____________________________

                                                                                                              ____________________________

                                                                                                              ____________________________

Insured’s phone if different from patient’s phone number                 ____________________________

 

 

 

The above information is true to the best of my knowledge.  I authorize my insurance benefits be paid directly to the physician, I understand I am financially responsible for any balance.  I also authorize Mid County Chiropractic or insurance company to release any information in order to process my claims.

 

Patient’s Signature_______________________________________________            Date______________________

                              ___Adult  Patient   ___Parent or Guardian   ___Spouse