Welcome to Medina Family Chiropractic and Acupuncture!

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Lenard Lawrence
5 years ago
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1 Welcome to Medina Family Chiropractic and Acupuncture! Please fill out this form and return it to the front desk. Let us know if you have any questions! Personal information Date: First name: Middle name: Last name: Preferred name: Address Street: City: State: Zip: Social Security #: Preferred phone number: Birthdate: Occupation: Marital status: M S W D Employer: How were you referred to us? Additional information Emergency contact name: Phone: Emergency contact relation: Primary Care Physician:

2 Insurance information Please provide a copy of your insurance card Insurance carrier: Name of policy holder: Date of birth of policy holder: Relationship of policy holder to you: Self Child Spouse Secondary insurance carrier: (if any) Authorization and release: I authorize payment of insurance benefits directly to Medina Family Chiropractic. I authorize Dr. Heather Martin or Dr. Angela Hobbs to release all information necessary to communicate with personal physicians and other health care providers and mayors and to secure payment of benefits. I understand that I am responsible for all costs of chiropractic care, regardless of insurance coverage. Patient s name (printed): Authorizing Signature: Date: Guardian s name if applicable: Personal information Race (circle one) American Indian or Alaska Native Native Hawaiian or Other Pacific Island Asian Black or African American t Hispanic or Latino Hispanic or Latino White Other Declined Unknown Preferred Language: (circle one) English Spanish Other:

3 Where applicable, specify the approximate date of your most recent: (month/ year) Physical exam: / Spinal Xray: / MRI: / Dental Xray: / CT Scan: / Other scans or X-rays: / Complaint #1 Where is your pain?: low back neck shoulder Other: When did your symptoms begin? (circle one) Today This week 3-6 months ago 6mo- 1 year Within last 3 months More than 1 year Which describes the frequency of your discomfort? Constant Frequent Intermittent Occasional Which describes the changes in your discomfort during the day? What helps relieve your discomfort? What activities are limited by your discomfort? What does the discomfort feel like? (sharp, dull, aching, etc) Does the discomfort radiate to other areas? How would you rate your discomfort on a scale of 0-10? It is worse in the morning It changes with weather Ice Heat Bending Bowel Movements Coughing Daily Routine Driving Getting up Lifting Lying down Pulling Pushing Moderate It is worse in the afternoon It is worse at night It does not change Medication Reading Sitting Sleeping Sneezing Standing Turning my head Urination Walking Working Excruciating

4 Complaint #2 Where is your pain?: low back neck shoulder Other: When did your symptoms begin? (circle one) Today This week 3-6 months ago 6mo- 1 year Within last 3 months More than 1 year Which describes the frequency of your discomfort? Constant Frequent Intermittent Occasional Which describes the changes in your discomfort during the day? What helps relieve your discomfort? What activities are limited by your discomfort? What does the discomfort feel like? (sharp, dull, aching, etc) Does the discomfort radiate to other areas? How would you rate your discomfort on a scale of 0-10? It is worse in the morning It changes with weather Ice Heat Bending Bowel Movements Coughing Daily Routine Driving Getting up Lifting Lying down Pulling Pushing Moderate It is worse in the afternoon It is worse at night It does not change Medication Reading Sitting Sleeping Sneezing Standing Turning my head Urination Walking Working Excruciating Social Health Do you smoke? Never smoker If former, quit year: Former smoker Current smoker If current, start year: If current, how much? Do you drink alcohol? Yes If yes, how many per week?

5 Medical history Have you been diagnosed with cancer? Has a physician ever diagnosed you with an emotional/ mental condition? Please list any falls, accidents, fractures, or dislocations: List any dates if applicable Please list any surgeries and dates of surgeries: Please list the medications you are currently taking: Womens Health History Most recent menstrual cycle: / / Are you pregnant? Yes EDD: Please circle if you have had the following conditions: Musculoskeletal Arthritis Gout Herniate disc Numbness/ tingling in hands Multiple Sclerosis Polio Osteoporosis TMJ Dysfunction Muscular Dystrophy Parkinson s Disease Numbness/ tingling in feet Sciatica Pinched Nerve Other: Sensory Health Blindness Cataracts Deafness or Hearing Loss Glaucoma Meniere s Disease Rhinitis Tinnitus Ear ringing Eczema Psoriasis Sinusitis Vertigo

6 Please circle if you have had the following conditions: Cardio-Pulmonary/ Circulatory Anemia Emphysema Hemophilia Hepatitis Hypotension Asthma HIV/ AIDS Other Lung Disorder Raynaud s Phenomenon Sickle Cell Anemia Chronic Sinus Infections Other Endocrine/ Gastrointestinal Lupus Rheumatoid Arthritis Scleroderma Crohn s Disease Headaches Diabetes Irritable Bowel Syndrome Liver Disease Thyroid Dysfunction Other Autoimmune Disorder Epilepsy Chronic Fatigue Syndrome Gallbladder problems Kidney Disease Seizures Unexplained Weight Loss Reproductive Health Infertility Cystitis Menopause Uterine Fibroid Prostate Enlargement Chronic Yeast Infections Medical history History of stroke or hypertension? Yes Do you have a pacemaker? Yes Do you have a congenital condition? Do you have any allergies (medications, food, seasonal)?

7 Please list all health conditions of immediate family: Family history is unknown I certify the information provided is accurate to the best of my knowledge: Name (printed): Signature: Guardian (if applicable, printed): Date:

Patient Profile. Full Name: Address: Work Phone: Date of Birth: Social Security #: (Circle One) Full Time / Part Time. Emergency Contact: Number:

Patient Profile. Full Name: Address: Work Phone: Date of Birth: Social Security #: (Circle One) Full Time / Part Time. Emergency Contact: Number: Patient Profile Full Name: Address: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security #: Email Address: Employer: (Circle One) Full Time / Part Time Emergency Contact: