Confidential Patient Information Date: E-mail: Name(first and last): Cell Phone: Sex: Male Female Marital Status: Date of Birth: Age: : Home Phone Address: City: State: Zip Code: Social Security #:     Occupation: Company Name Location: Work Phone Number:         Guardian/Spouse's Full Name: Guardian/Spouse's Date of Birth: Guardian/Spouse's Social Security #: Guardian/Spouse's Employer Location: Work Phone Number:         Name of nearest relative (not your spouse): Phone: Who referred you to our office? Were you referred to a certain doctor in this office? Is your visit due to an accident? No Yes (if yes, please see receptionist for an injury report.) YOUR PRESENT COMPLAINT BRIEFLY DESCRIBE YOUR SYMPTOMS List other doctor's seen for this condition: Personal Medical history (if any of the following are relevant to your medical history, please check the accompanying box:) Cancer Muscular Dystrophy Rheumatic Fever Digestive Disorders Polio Multiple Sclerosis Scarlet Fever Sinus Trouble Tuberculosis Convulsions Nervousness Backaches High Blood Pressure Epilepsy Asthma Numbness Heart Trouble Concussion Dizziness Arthritis Diabetes Hepatitis German Measles Venereal Disease Describe any operations you've had and the dates: Have you been treated by a physician for any health condition in the last year? Yes No Describe Condition: Date of last physical exam: Are you taking any medication: Yes No What kind? Are you allergic to anything? Yes No What? Are you pregnant? Yes No Date of last menstrual period: Do you have insurance? Yes No Company: I.D. No. Policy Group No. I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that this office may prepare any necessary reports and forms to assist me in making collection from the insurance company and that my amount authorized to be paid directly to this will be credited to my account upon receipt. I permit this office to endorse co-issued remittances for the conveyance of credit to my account. However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. It is my understanding that my credit may be checked if Chiropractic Wellness Center extends credit to me and I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered to me will be immediately due and payable unless prior arrangements are made. I hereby authorize the doctors at Chiropractic Wellness Center and whomever they may designate as their assistants to administer treatment as they so deem necessary and I also authorize the release of any information acquired in the course of my examination or treatment. I certify that the above information is true and correct. Patient's (Parent or Guardian's) Signature:

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