PATIENT REGISTRATION

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PATIENT REGISTRATION Last Name First Name MI Street Address City State Zip Code Social Security # - - Email Address Home Phone( ) Cell Phone( ) Sex Male Female of Birth Age Marital Status Married Single Divorced Widowed Partnered Minor Patient Employer/School Occupation Employer Phone( ) Employer/School Address Spouse s Name Spouse s Employer In Case Of Emergency, Contact: Name Relationship Home Phone ( ) Cell Phone( ) Are any of your family members or friends in need of chiropractic care? Yes No Ortega Chiropractic Corp.- 5367 ORTEGA Boulevard- Jacksonville, FL 32210 (904) 425-4545 1 P a g e

HEALTH HISTORY What treatment have you already received for your condition? Medication Surgery Physical Therapy Chiropractic None Other Name of other doctor(s) who you have seen for this condition of Last: Physical Exam X-ray MRI/CT Please Circle if you have had any of the following: AIDS/HIV Chicken Pox Liver Disease Rheumatoid Arthritis Alcoholism Diabetes Measles Rheumatic Fever Allergies Emphysema Migraines Scarlet Fever Anemia Epilepsy Miscarriage Stroke Anorexia Fractures Multiple Sclerosis Suicide Attempt Appendicitis Glaucoma Mumps Thyroid Problems Arthritis Goiter Osteoporosis Tonsillitis Asthma Gout Pacemaker Tuberculosis Bleeding Disorders Heart Disease Parkinson s Tumors, Growths Breast Lump Hepatitis Pinched Nerve Typhoid Fever Bronchitis Hernia Pneumonia Ulcers Bulimia Herniated Disc Polio Vaginal Infections Cancer Herpes Prostate Problem Venereal Disease Cataracts High Cholesterol Prosthesis Whooping Cough Chemical Dependency Kidney Disease Psychiatric Care Other Exercise: None Moderate Daily Heavy Work Activity: Sitting Standing Light Heavy Habits: Smoking Alcohol Coffee/Caffeine List Surgeries and s Medications 2 P a g e

Name: : Pain Evaluation Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain) Please mark an x on the picture where you have pain, numbness, or tingling. Left Back Right Right Front Left When did your symptoms first appear? Is this condition getting progressively worse? Yes No Type of Pain: Sharp Dull Burning Shooting Stiffness Aching Tingling Cramping Numbness Swelling Other Is this pain constant? Yes No How does this condition impact your. a) Home Life b) Work Life c) Social Life Rate your commitment to fix this problem on a scale of 1(none ) to 10(total) 3 P a g e

Informed Consent for Chiropractic Care Chiropractic care, like all forms of health care, while offering considerable benefits may, also provide some level of risk. This level of risk is most often very minimal; yet in rare cases, injury has been associated with chiropractic care. These types on complications that have been reported secondary to chiropractic care include sprain/strain injuries, irritation of a disk condition, and rarely, fractures. One of the rarest complications associated with chiropractic care, occurring at adjustments, may be veritable artery injury that could lead to stroke. Prior to receiving chiropractic care at this Chiropractic office, a health history and physical examination will be completed. These procedures are performed to assess your specific condition, your overall health and, in particular, your spinal health. These procedures will assist us in determining if chiropractic care is needed, or if any further examinations or studies are needed. In addition, they will help us determine if there is any reason to modify your care or provide you with a referral to another health care provider. All relevant findings will be reported to you along with a care plan prior to beginning care. I understand and accept that there are risks associated with chiropractic care and give my consent to the examinations that the doctor deems necessary, and to the chiropractic care including spinal adjustments, as reported following my assessment. Patient Name (printed) Relationship to Patient Patient or legal Guardian (signature) _ Witness Signature (office staff) _

Ortega Chiropractic 5367 Ortega Blvd Jacksonville, FL 32210 904-425-4545 904-425-4548 Fax ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I hereby acknowledge that I have received and had an opportunity to ask questions concerning the above named practice s Notice of Privacy Practices. d: Patient or Patient s Representative Print Patient s Name If signed by Representative, state name of Representative Relationship to Patient

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