Test Form

First Name

Middle Name

Last Name

Nickname

Address

City

State

Zip Code

Social Security

Sex Sex Male Female

Marital Status Marital Status M S D W

Spouse / Parent Name

Preferred Language

Race / Ethnicity

Date of Birth

Age

LBS

HGT

Pregnant Pregnant Yes NO

Contact Information Contact Information

H.Phone

Cell Phone

Work Phone

Cell Carrier

Contact Preference Contact Preference Hm Ph Work Ph Cell Ph

Email Email Wk Hm

Home Email Address

Work Email Address

Emergency Contact

Phone

Your Occupation

Employer

Insurance Insurance Please provide us with your insurance card(s) along with a photo ID. In addition, please complete the following:

Are you the policy holder? Are you the policy holder? Yes No

If Yes, Who is?

Policy Holder's Name

DOB

Policy Holder's Social Security#

Policy Holder's Employer

Do u have Secondary Insurance? Do u have Secondary Insurance? Yes No

IF yes, Complete the following? IF yes, Complete the following?

Policy Holder's Name

DOB

Policy Holder's Social Security#

Policy Holder's Employer

Patient History Patient History

Have you ever received Chiropractic Care? Have you ever received Chiropractic Care? Yes No

If yes, When?

Name of most recent Chiropractor

Please give a brief description of the problem(s) you are experiencing in order of severity Please give a brief description of the problem(s) you are experiencing in order of severity

For how long?

What makes the pain feel better

what makes the pain feel worse

Is/Are the problem(s) getting Better, Worse or the Same?

When did the problem(s) start?

What appears to be the initial cause?

Are you seeing any other providers for other problems or health conditions? Are you seeing any other providers for other problems or health conditions? Yes No

Past History Past History

Have you ever had any surgeries or Hospitalizations?

If Yes please List

Please list any current or past injuries and illnessess not listed above:

If yes, date of accident:

Do you smoke? Do you smoke? Yes No

FAMILY MEDICAL HISTORY FAMILY MEDICAL HISTORY

Do you have a family history of: (Please indicate all that apply) Do you have a family history of: (Please indicate all that apply) Cancer Strokes Headaches Cardiac Disease Neurological Disease Adopted/Unknown Cardiac Disease below age 40 Psychiatric Disease Diabetes None of the above

Other

MEDICATIONS MEDICATIONS

What medications are you currently taking? Please include all non-prescription and over the counter

ALLERGIES ALLERGIES

Do you have any allergies? Please indicate what they are and how severe.

The rating scale below is designed to measure how your condition affects your ACTIVITIES OF DAILY LIVING. On a scale of 0- 10 with 0 being no pain at all and 10 being the worst pain you’ve had. The rating scale below is designed to measure how your condition affects your ACTIVITIES OF DAILY LIVING. On a scale of 0- 10 with 0 being no pain at all and 10 being the worst pain you’ve had. 0 (No Pain) 1 2 3 4 5 6 7 8 9 10 ( To Much Pain)

Does your Condition cause any pain or restrictions while doing any of the following activities, please rate the following. Does your Condition cause any pain or restrictions while doing any of the following activities, please rate the following.

Work (0-10)