New Patient Information Form:

NEW PATIENT INFORMATION: PART 1

SAN DIEGO CHIROPRACTIC CARE CENTER

1. ABOUT YOU

Today's Date______/______/______                                   File#_______________

Patient Name: ______________________________________________________
                           LAST                                        FIRST                         MI
What You Prefer To Be Called:_____________________Male   Female

Birthdate:_______/_______/_______ Age:______ SS#:__________________________

Mailing Address:__________________________________________________________

_______________________________________________________________________
                           CITY                            STATE                   ZIP

Home Phone #:__________________________________________________________

Work Phone #:________________________________________ Ext:_______________

Other Phone #s:_____________________Cell Phone________________________

E-Mail Address:__________________________________________________________

Referred By:____________________________________________________________

Employer:________________________________________How Long?_____________

Employer's Address:_____________________________________________________

______________________________________________________________________
                           CITY                            STATE                   ZIP

Occupation:____________________________________________________________

Status:MinorSingleMarriedDivorcedSeperatedWidowed

Spouse's Name:________________________________________________________

Do you have kids? Yes No     How Many?_________________________

2. INSURANCE INFO

Co. Name:_____________________________________________

Address:_______________________________________________

Phone #:_______________________________________________

Group #:_______________________________________________
(Plan, Local or Policy #)

Insured's SS#:__________________________________________

Insured's Name:________________________________________

Relation:______________________________________________

Date of Birth of Insured:_______/_______/________

3. REASON FOR VISIT
The reason for this visit is a result of: WorkSportsAutoTrauma or ChronicWellness Care
(Explain what happened):

______________________________________________________________________________________________________
Please describe the pain and its location:

______________________________________________________________________________________________________

When did condition begin?_____/_____/_____ Time of day:___________________
Is the condition getting worse? Yes No Constant Comes and goes

Is this condition interfering with your (Please circle)     work     sleep     daily routine
If so, please explain:___________________________________________________________________________________

Have you ever had this or similar conditions in the past?     Yes      No
If so, please explain:___________________________________________________________________________________

Have you ever been treated by a medical physician for this condition?     Yes      No
If so, where?__________________________________________________________________________________________

Have you ever been treated by a Chiropractor before?    Yes      No
If so, whom?__________________________________________________Phone #:__________________________________

NEW PATIENT INFORMATION: PART 2

SAN DIEGO CHIROPRACTIC CARE CENTER

4. IN EVENT OF EMERGENCY

Who should we contact?___________________________________________________________________________________________

Relation__________________________________________________________________

Home Phone #:____________________________ Work Phone_____________________Cell Phone_____________________________

Who is your Medical Doctor?_________________________________________________ Phone #:______________________________

5. HEALTH HISTORY
Are you taking any of the following medications?
Nerve pills Pain Killers (including aspirin)Muscle relaxers Stimulants
Blood ThinnersTranquillizersInsulin Other(s):_______________

Do you have or ever have had any of the following diseases or conditions? Circle Y or N.

Y N Heart Attack/Stroke
Y N Congenital Heart Defect
Y N Alcohol/Drug Abuse
Y N HIV/AIDS
Y N Frequent Neck Pain
Y N High/Low Blood Pressure
Y N Severe Frequent Headaches
Y N Fainting/Seizures/Epilepsy
Y N Diabetes / Tuberculosis
Y N Lower Back Problems

Y N Heart Surg/Pacemaker
Y N Mitral Valve Prolapse
Y N Venereal Disease
Y N Shingles
Y N Emphysema / Glaucoma
Y N Psychiatric Problems
Y N Kidney Problems
Y N Sinus Problems
Y N Difficulty Breathing
Y N Artificial Bones / Joints

Y N Heart Murmur
Y N Artificial Valves
Y N Hepatitis
Y N Cancer
Y N Anemia
Y N Rheumatic Fever
Y N Ulcers / Colitis
Y N Asthma
Y N Chemotherapy
Y N Arthritis

Please list any other serious medical condition(s) past and present:

______________________________________________________________________________

List previous surgeries/treatments with dates:________________________________________

______________________________________________________________________________

Family Health History:___________________________________________________________

______________________________________________________________________________
Do you take supplements or Vitamins? Yes NO Exercise Yes No
Are you on a special diet? Yes NO Since: _______/_______/_______
Do you smoke? No Yes / How Much?_________________How long?____________
Are you wearing: Heal lifts Sole lifts Inner soles Arch supports
For women: Are you taking Birth Control? Yes No
Are you pregnant? No Yes / How long?________________Nursing? Yes No

6. ACCOUNT INFO
Person ultimately responsible for account:

Name:_________________________

Relation:_______________________

Billing Address:__________________

_______________________________

_______________________________
City State Zip

SSN:__________________________

D.L.#:_________________________

Work Phone #:__________________

Payment Method:
Cash Check Credit Card

(Initials)_______I hereby authorize assignment of my insurance rights and benefits directly to the provider for services rendered. I fully understand I am solely responsible for any balance not paid for by my insurance company.

*We invite you to discuss with us any questions regarding our services. The best health services are based on a friendly, mutual understanding between provider and patient.

*Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with the business manager. If account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, and any other expenses incurred in collecting your account.

*I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider and or managed care organization, to release any information required to process insurance claims. I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided.

Signature:________________________________________________ Date:______/______/______
Adult Patient Parent or Guardian Spouse