MARTIN CHIROPRACTIC

Patient Information

Date:        ____ / ____ / ____         Marital status:                o Single                o Married               o Divorced             o Widowed            o Separated

Name:      Last:        _______________________    First:   _______________________   MI:  __________                    DOB:      ____ / ____ / ____

Address:  ______________________________________    City:        ________________                State:  _____           Zip:                ________________

SSN:       ______ / ______ / _______                    Email:                ________________________________________________________________________

Phone:     ( ____ ) - _____ - _______     (home)                     ( ____ ) - _____ - _______ (cell)                            ( ____ ) - _____ - _______ (work)

Emergency Contact:                Name: _______________________      Relationship            __________________            ( ____ ) - _____ - _______

How did you hear about our practice?    o Internet               o Advertisement                 o Friend, if yes, who? _____________________

Have you had Chiropractic care before?                                o Yes     o No      Whom?    __________________            When:      ____ / ____ / ____

Have you seen another doctor for these symptoms?              o Yes     o No      Whom?    ____________________        When: ____ / ____ / ____

Who is your primary care physician?     ________________________________     Are you currently under medical care?              o Yeso No

List any medications you are currently taking:                                _______________________________________________________________________________

List any surgeries & hospitalizations:                                     _______________________________________________________________________________

Employment Information                                      Work status:         o FT       o PT       o Retired                Student:   o Yes

Employer: _____________________________    Phone:     ( ____ ) - _____ - _______     Occupation:                ­­­­­­­­­­­­­­­­­­­­­­______________________________

Address:  _______________________________City:        ________________                State:  _____                           Zip:                ________________

Financial Information ~ Health Insurance         (please provide us with a copy of your insurance card.)

Name of Carrier:     __________________   Policy #:____________________   Group #:  _________    Telephone #:( ____ ) - _____ - _______

Secondary Ins:        __________________   Policy #:____________________   Group #:  _________    Telephone #:( ____ ) - _____ - _______

PERSONAL INJURY PATIENTS ONLY

Accident Information:

Is this visit due to an accident?               o Yes   o No          Date of Accident:             ____ / ____ / ____                Was it reported?   o Yes o No

Is there an accident report?                     o Yes o No          Name of Insurance company responsible for accident___________________________

Policy #:____________________________________          Telephone #:           ( ____ ) - _____ - _______                     DL#:                ________________

Is there an attorney involved?             o Yeso No           If yes, Whom:  ________________________

Attorney Address#:____________________        Telephone #: (____ ) - _____ - _______                Letter of Protection?               o Yes o No

What is your complaint today?                      Where does it hurt?

o Cervical Pain      (neck)                     o Thoracic Pain     (mid back)             o Leg Pain             (Rt/  Lt)                 o Headache

o Shoulder Pain     (Rt/  Lt)                 o Lumbar Pain       (low back)              o Knee Pain           (Rt/  Lt)                o Sacroiliac Pain (SI)

o Arm Pain            (Rt/  Lt)                 o Buttock Pain       (Rt/  Lt)                 o Foot Pain        rmation necessary, including the diagnosis and the records of any exam or treatment rendered to me, in order to secure the payment of benefits.  I authorize the use of this signature on all insurance claims, including electronic submissions.