CONFIDENTIAL PATIENT HISTORY FORM
Please answer all questions or write N/A (if it does not apply )-Thanks!
Confidential Health History:
Today's Date:
Name: Soc. Sec. # Home Phone: Address: City: State: Zip: Age: Birthdate: Male Female Status: M S W D # of Children: Occupation: Employer: Work Phone: E-Mail Address Spouse Name: Spouse's Occupation: Spouse Employer: Town: Work Phone:
Name of person whose policy you are on:
Their Date of Birth:
In Case of Emergency: Who is your nearest living relative (for emergency use please list name/address/phone):
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Please answer all question or enter N/A if it does not apply -- Thank you
Present Health Concern What is the major health problem that has caused you to seek care in our office:
1. Currently this problem is : improving? staying the same? getting worse? 2. Does it interfere with : work sleep daily routine other 3. List other Drs. you've seen for this problem: Dr. specialty treatment Dr specialty treatment Dr. specialty treatment Did their treatment help?: yes no, temporary relief only.
4. Was your major health problem caused by: auto accident? Y N Date: job accident? Y N date other
*Are any of these accident cases still open and in litigation ? Y N *Will you be requesting copies of claims or a statement of services? Y N
5. Have you had chiropractic care before? If yes, Dr.? When? For what problem? same or other 6. Habits: Do you smoke? Y N, If yes pks./day? Other? Do you consume alcohol? Y N, If yes: Light, Moderate Heavy 7. When was the last time you felt really good?
Past/Present Health History: If this pertains to you…
Please list (and include dates) if you've ever had. . . 1. any serious injury or chronic illnesses (requiring medical treatment) Yes No If yes: 2. any surgery (list type and date) Yes No . If yes: 3. any significant falls/fractures in your lifetime(list type and date)? Yes No If yes: 4. any automobile / job accidents? Y N If yes, When? 5. Did you receive any treatment? Y N. For which accident? By Whom & for which accident?
If your injury is job related: Are you working now? Y N . Have you lost any work days? Y N If yes, what days have you lost ? Was the injury reported to your supervisor and an incident report made? Y N Have you been unable to resume work due to this injury? Y N 6. Have you been treated by a Dr. for any health conditions in the last year? Y N If yes, what were they?: 7. Are you taking any medication Y N . (List:name, dosage, Dr. and reason prescribed) *please spell drug name correctly (refer to bottle or prescription) If yes, drug dosage Dr. reason drug dosage Dr. reason drug dosage Dr. reason drug dosage Dr. reason Any others?: List over the counter medications here: 8. If you have a family medical doctor/clinic that you use, please note: Name town/location phone #
********* *** For women only: The following information is essential in order to determine if x-rays can be taken and what treatment procedures will assure you the greatest results and safety.-Thank you! Are you pregnant at this time ? Y N . Are you trying to become pregnant at this time? Y N Are you taking any medication,( including birth control) Y N . Explain? Do you smoke at all? Y N . If yes… How much? ********* *Please note: In order to keep care as affordable as possible by reducing billing expenses, our office policy requires that payment be made at the time of your office visit . What method of payment will you be using today?
Cash Check Credit card ********* I hereby authorize Dr. Bruce Schneider or his assistants to examine me and take any x-rays deemed necessary by the Doctor. I further authorize any treatment deemed necessary by the Doctor for myself (or my children ,if applicable). I authorize the Doctor to release or obtain my records to/from my insurance company, attorney, or my other doctors, if needed. *** If I am a female patient, I will notify the Doctor of any chance that I may be pregnant before any x-rays are ever taken and before any treatment is administered.)*** If I have health insurance and use it for chiropractic services, I accept that any unpaid balance is my responsibility, which includes deductibles, co-payments and any services that my insurance company decides not to pay for, regardless of their reason. This applies to automobile and work related injury cases as well. I request that my insurance benefits be assigned to the doctor. Any collection costs incurred on my account are my responsibility. I certify that the above information is accurate and truthful, that I understand the policies of the office and that I present to Dr. Schneider for evaluation and/or treatment of a health related condition and for no other purpose. Copies of x-rays or records will be at my expense and require 1 weeks written notice.
Signature of Patient____________________________________________________ If patient is a minor, Signature of parent and/or guardian_______________________ Witness by:________________________ date: ____/____/____
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