Confidential Patient Data
IF YOU NEED ANY ASSISTANCE COMPLETING THIS FORM, PLEASE ASK THE RECEPTIONIST

PATIENT INFORMATION                                       Today's Date: _____________   

Name: _____________________________________________ Date of Birth: _________________
Address: _______________________________ City: _________________ State: ___ Zip: _______ 
Home Phone #:_________________ Cell #:__________________ Work #: ___________________ 
Social Security #:_________________ Age: _______    q Male   q Female 
Marital Status: q Married  qSingle  qDivorced  qSeparated  qEmail:___________ __________
Name of Spouse or Nearest Relative: _________________________    Phone: _______________
Your Occupation____________________________   Your Employer: _______________________
Referred to this Office by:  qFriend/Family Member - Name? ______________________________
                            qYellow Pages   q Mail   qClinic Location qOther_______________
Payment for Services will be by:   qCash   qCheck   qCredit Card  qHealth Insurance
                                   qAutomobile Insurance   qWorker's Compensation
Name of Insured If Other Than You: ____________________________________DOB:__________
Name of Insurance Co.:_____________________________ Insured's Employer: _______________ Insured's Social Security #:_____________________ Employer's Phone #:____________________
Are you covered by more than one insurance company?  qYes qNo 
If So Secondary Insurance Info: ______________________________________________________

MEDICAL/FAMILY HISTORY  S = Self   M = Mother    F = Father
(Please indicate which conditions have been experienced by the above by marking appropriate boxes).
S     M     F		S     M     F		       S     M     F
q    q    qAIDS	   	q    q    qdislocated joints		q    q    qneck pain    
q    q    qanemia		q    q    qepilepsy			q    q    qnervousness
q    q    qarthritis		q    q    qGerman measles		q    q    qnumbness
q    q    qasthma		q    q    qheadaches			q    q    qpolio
q    q    qback pain		q    q    qheart trouble			q    q    qpoor circulation 
q    q    qbladder trouble	q    q    qreproductive disorders		q    q    qhepatitis
q    q    qbone fracture	q    q    qhigh blood pressure		q    q    qrheumatic fever 
q    q    qcancer		q    q    qHIV/ARC			q    q    qrheumatism
q    q    qchest pain	q    q    qkidney disorders		q    q    qscarlet fever 
q    q    qconcussion	q    q    qbowel control loss		q    q    qsinus trouble
q    q    qconvulsions	q    q    qmenstrual cramps		q    q    qstroke
q    q    qdiabetes		q    q    qmultiple sclerosis		q    q    qtuberculosis
q    q    qindigestion 	q    q    qmuscular dystrophy		q    q    qvenereal disease     
Have you been treated by a physician for any health condition in the last year?  qYes    qNo
Describe Condition________________________________________________ Date of Last Physical Exam__________

SURGICAL HISTORY:
1._________________________________________________________________________Date:________________
2._________________________________________________________________________Date:________________
3._________________________________________________________________________Date:________________
Have you ever had a metal implant?    qYes     qNo                    Ever been gunshot?     qYes     qNo
ACCIDENT HISTORY: qJob  qAuto   qOther  1. __________________________Date:________________
		qJob  qAuto   qOther  2.___________________________Date:________________
  	      	qJob  qAuto   qOther  3.___________________________Date:________________

(over please)
PLEASE DESCRIBE PRESENT MAJOR COMPLAINTS: 
Please Rate Your Symptoms (1-5, with 1 being the most serious condition bothering you today)  

1._________________________________________________________________________________________

2._________________________________________________________________________________________

3._________________________________________________________________________________________

4._________________________________________________________________________________________

5._________________________________________________________________________________________
 
SYMPTOMS ARE WORSE:               qMORNING     qAFTERNOON     qNIGHT  qCONSTANT
WHEN AND HOW OCCURRED? ___________________________________________________________________

______________________________________________________________________________________________

SYMPTOMS DEVELOPED FROM: qJOB RELATED INJURY     qAUTO ACCIDENT     qOTHER ACCIDENT      qILLNESS    qUNKNOWN CAUSE  qGRADUAL ONSET      DATE OCCURRED:_______________________                       

SYMPTOMS HAVE PERSISTED FOR # ____HOUR(S)   ____DAY(S)   __WEEK(S)   ___MONTH(S)   ___YEAR(S)

SYMPTOMS/COMPLAINTS:     qCOME & GO       qARE CONSTANT

HAVE YOU EVER HAD THIS BEFORE:     qNO      qYES    WHEN? ___________________________________

NAME AND LOCATION OF DOCTORS PREVIOUSLY SEEN FOR PRESENT CONDITION(S):
_______________________________________________________________________________________________
_______________________________________________________________________________________________

ARE YOU ALLERGIC TO ANY MEDICATIONS:  qNO    qYES   WHAT KIND?_____________________________
_______________________________________________________________________________________________

ARE YOU TAKING ANY MEDICATIONS    qNO qYES    WHAT KIND?_________________________________ _______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
ARE YOU PREGNANT	qNO	qYES   DATE OF LAST MENSTRUAL PERIOD____________________________	

PLEASE CHECK THE FOLLOWING ACTIVITIES THAT AGGRAVATE YOUR CONDITION:
qBENDING qREACHING qSTRAINING AT STOOL qCOUGHING qSITTING qTURNING HEAD		
qLIFTING qSNEEZING qWALKING qLYING DOWN qSTANDINGqOTHER______________________________

PLEASE CHECK THE FOLLOWING ACTIVITIES THAT RELIEVE YOUR CONDITION:
qBENDING qSITTING qLIFTING qSTANDING qLYING DOWN qTURNING HEAD qSTRETCHING qWALKING
qOTHER_______________________________________________________________________________________

PLEASE CHECK ANY ADDITIONAL SYMPTOMS YOU MAY BE EXPERIENCING:
qblurred vision     qbuzzing in ears     qcold feet     qcold hands     qcold sweats      qconcentration loss /confusion qconstipation      qdepression /weeping spells      qdiarrhea  qdizziness   qface flushed qfainting     qfatigue      qfever     qhead seems too heavy     qheadaches     qinsomnia     qlight bothers eyes qloss of balance  qloss of smell     qloss of taste  qlow resistance to colds     qmuscle jerking    qnumbness in fingers  qnumbness in toes    qpins and needles in arms    qpins and needles in legs    qringing in ears   qshortness of breath  qstiff neck  qstomach upset  qOther_________________________________________________________________________________

Patient's Signature: __________________________________    Date:______________________