Chiropractic Case History/patient Information Form Page 2

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Do you have any allergies of any kind? □ Yes
□ No
If yes, describe:______________________________________________________________________________
Please
list
any
other
health
problems
you
have,
no
matter
how
insignificant
they
may
be:_________________________________________________________________________________________
___________________________________________________________________________________________
SOCIAL HISTORY:
Do you drink alcoholic beverages?___ If so, how much per week?__________________________________
Do you use any tobacco products?______Do you smoke?____ If so, packs per day: _______________________
Do you take vitamin supplements?________ If so, please list:______________________________________
Do you consume caffeine?____ If so, how much per day:__________________________________________
Do you exercise?__________ If yes, what is the frequency and type of exercise?__________________________
What are your hobbies?________________________________________________________________________
What percentage of time during the day (at home or at your job away from home) do you spend:
lifting_____ sitting_____ bending______working at a computer_______
FAMILY HISTORY:
Parents:
Father: living___ deceased____ Current age if still living:______ Cause of death and age at death if
deceased:____________________ (check one)
Mother: living___ deceased____ Current age if still living:______ Cause of death and age at death if
deceased:____________________ (check one)
Check if applicable to you: _________ As an adopted child, little is known of birth parents or family.
Do you have any family members who suffer from the same condition you do?
If so, please
list:___________________________________________________________________________________
FAMILY DISEASES (check if applicable and indicate whether family member is Father, Mother, Sister, Brother):
Tuberculosis____
Cancer____
Mental Illness____
Diabetes ____
Asthma____
Heart Disease ____
Stroke ____
Kidney Disease____
Lung Disease____
Arthritis_____
Liver Disease ____
Other ________________________________________
Please check any and all insurance coverage that may be applicable in this case:
 Major Medical
 Worker's Compensation  Medicaid  Medicare
 Auto Accident
 Medical Savings Account & Flex Plans  Other
Name of Primary Insurance Company:___________________________________________________________
Name of Secondary Insurance Company (if any):___________________________________________________
AUTHORIZATION AND RELEASE: I authorize payment of insurance benefits directly to the chiropractor or
chiropractic office. I authorize the doctor to release all information necessary to communicate with personal
physicians and other healthcare providers and payors and to secure the payment of benefits. I understand that I am
responsible for all costs of chiropractic care, regardless of insurance coverage. I also understand that if I suspend
or terminate my schedule of care as determined by my treating doctor, any fees for professional services will be
immediately due and payable.
The patient understands and agrees to allow this chiropractic office to use their Patient Health Information
for the purpose of treatment, payment, healthcare operations, and coordination of care. We want you to
know how your Patient Health Information is going to be used in this office and your rights concerning
those records. If you would like to have a more detailed account of our policies and procedures concerning
the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is
available to you at the front desk before signing this consent. If there is anyone you do not want to receive
your medical records, please inform our office.
Patient's Signature:_____________________________________________________
Date:________________
Guardian's Signature Authorizing Care:_____________________________________
Date:________________

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