| First Name Last Name Date |
| Adress City State Zip |
| Phone Social Security# Driver Lic.# |
| Age Birthday GenderMaleFemale StatusMSWD No. Children |
| Occupation Employer Years Employed Employer's Phone |
| Spouse's Name Occupation Employer |
| Person Responsible for this account Referred by |
| What's your major complaint? |
| Other Complaints |
| How long have you had this condition? Have you had this or similar conditions in the past? |
| What activities aggravate your conditions? |
| Is this condition getting progressively worse? Yes No Constant Comes and Goes |
| Is this comdition interfering with your: Work Sleep Daily Routine Other |
| How long has it been since you really felt good? |
| List surgical operations: |
| Are you taking any medications? What Kind? |
| Any non-prescription drugs? What Kind? |
|
Other Doctors seen for this condition: MD DC DO DDS
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| Doctor's name Diagnosis |
| X-rays Urinalysis Blood Tests Other |
| Treatment: Medication Physiotherapy |
| Results Length of time under care |
| Were you off work? If so, how long have you returned to your same job? If not, why |
| INSURANCE INFORMATION: |
| Do you have any group, union or personal health and accident insurance? Yes No |
| Name of Insurance Company Claim# Group# |
| Address Phone Agent |
| Additional Insurance Company Claim#Group# |
| Address Phone Agent |
| Is your condition due to an accident? Illness Other |
| ACCIDENT INFORMATION: |
| Did your accident occur while at work? Yes No Were you involved in an automobile accident? Yes No |
| Date Time Injury roported to employer? Yes No Name of the Supervisor |
| Description of accident |
|
| Were you injured? How? |
| Location |
| Were you unconscious? Fractures Cuts Abrasions Bruises |
| Patient taken to |
| Confined to hospital for Days Hous. Name of hospital doctor |
| Have you had any other personal injury or accident? Past year Past 5 years Over 5 years None |
| Describe |
| Do you have an attorney? Yes No Name and Address |
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| I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered to me will be immediately due and payable. |
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| Patient's Signature Date: |
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