Patient Name

First Name

Last Name

Today’s Date

Date of Birth

Age

Gender

Address

Street Address

Street Address 2

City

State

Zip Code

Country

Home Phone (With area code)

Cell Phone (With area code)

Work Phone (With area code)

Patient E-Mail

Children

Name of Child 1

Age of 1st Child

Gender 1st Child

Name of Child 2

Age 2nd Child

Gender 2nd Child

Personal Details

Employer

Occupation

Marital Status

Single Married Divorced Widowed Separated Domestic Partner

Spouse’s Name

Spouse’s Date of Birth

Contact in case of Emergency

Emergency Contact Phone

Whom may we thank for referring you to this office?

Name of Primary Insurance

Name of Insured

Insured Date of Birth

Insured SSN#

Name of Secondary Insurance

Name of Insured

Insured Date of Birth

Insured SSN#

CONSENT FOR A MINOR/CHILD

IF THIS HEALTH PROFILE IS FOR A MINOR/CHILD, PLEASE FILL OUT AND SIGN BELOW WRITTEN CONSENT FOR A CHILD. I AUTHORIZE THE CHIROPRACTIC STAFF TO PERFORM DIAGNOSTIC PROCEDURES, RADIO-GRAPHIC EVALUATIONS, RENDER CHIROPRACTIC CARE AND PERFORM CHIROPRACTIC ADJUSTMENTS TO MY MINOR/CHILD. AS OF THIS DATE, I HAVE THE LEGAL RIGHT TO SELECT AND AUTHORIZE HEALTH CARE SERVICES FOR MY MINOR/CHILD. IF MY AUTHORITY TO SELECT AND AUTHORIZE CARE IS REVOKED OR ALTERED, I WILL IMMEDIATELY NOTIFY THIS OFFICE.

Chiropractic Health Profile

HEALTH CONCERNS

CONSENT FOR A MINOR/CHILD

Patient Name

First Name

Last Name

Today’s Date

Date of Birth

Age

Gender

Address

Street Address

Street Address 2

City

State

Zip Code

Country

Home Phone (With area code)

Cell Phone (With area code)

Work Phone (With area code)

Patient E-Mail

Children

Name of Child 1

Age of 1st Child

Gender 1st Child

Name of Child 2

Age 2nd Child

Gender 2nd Child

Personal Details

Employer

Occupation

Marital Status

Spouse’s Name

Spouse’s Date of Birth

Contact in case of Emergency

Emergency Contact Phone

Whom may we thank for referring you to this office?

Name of Primary Insurance

Name of Insured

Insured Date of Birth

Insured SSN#

Name of Secondary Insurance

Name of Insured

Insured Date of Birth

Insured SSN#

HEALTH CONCERNS

Primary Health Concern

Severity (10=Unbearable)

Episode Start Date

Result of Injury?

Are Symptoms?

Additional Health Concern 1

Severity 1 (10=Unbearable)

Episode Start Date 1

Result of Injury? 1

Are Symptoms 1

Additional Health Concern 2

Severity 2 (10=Unbearable)

Episode Start Date 2

Result of Injury 2 ?

Are Symptoms 2

Additional Health Concern 3

Severity 3 (10=Unbearable)

Episode Start Date 3

Result of Injury 3 ?

Are Symptoms 3

Additional Health Concern 4

Severity 4 (10=Unbearable)

Episode Start Date 4

Result of Injury 4 ?

Are Symptoms 4

Condition(s) ever been treated by anyone in the past?

If Yes which profession?

If yes, please list when and by whom?

Check all that apply

Check any condition you have now / have had:

List all surgical operations and years

List all over the counter and prescription medications you are on:

When was your last auto accident

Have you had previous chiropractic care?