Above and Beyond Chiropractic Family Health Center, Ltd.

Name___________________________________________________ Date__________________

Address_______________________________________________________________________

City___________________________________ State_______________ Zip_________________

Home Phone_________________________________ Work Phone________________________

Cell Phone___________________________________ Email_____________________________

Date of Birth_____________________________ Age_________________  Sex     M         F

(Circle One)     Married     Widowed     Single    Minor     Separated     Divorced     Life Partner

Occupation__________________________________ Hours worked per week________________

Employer/School_________________________________________________________________

In case of emergency contact_____________________________ Phone______________________

Patient Medical History

Do you or have you had:

Vision Problems                                  __No  __Yes                   Sinus Problems                  __No  __Yes

Frequent  diarrhea, constipation     __No  __Yes                   Frequent Heartburn            __No  __Yes

Heart, Kidney, Liver, Bladder probs   __No  __Yes                    Allergies                            __No  __Yes

Skin Problems (eczema, psoriasis)      __No  __Yes                    Breathing/Lung problems    __No  __Yes

High or Low Blood Pressure              __No  __Yes                    Cancer of any kind             __No  __Yes

Tension Headaches                            __No  __Yes                    Arthritis                              __No  __Yes

Migraine Headaches                          __No  __Yes

Do you or have you had pain/discomfort in your:

Neck           __No  __Yes               Middle Back          __No  __Yes            Shoulder        __No  __Yes

Hip, knee     __No  __Yes               Jaw                        __No  __Yes            Low back      __No  __Yes

Foot, ankle  __No  __Yes       Between shoulder blades __No  __Yes  Elbow, wrist, hand   __No  __Yes

Describe any other health problems you may be experiencing:

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Do any health complications run in your family? Please list:

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Surgeries (including cosmetic or elected surgeries):

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Medications you are presently taking and for what:

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Nutritional supplements presently taking:

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Do you have children?     Yes     No                 If yes, how many?_________________________

Do you smoke?               Yes     No                 Do you consider yourself a healthy person?  Yes      No

(Complete the following part in office please.)

Privacy of Health Information

I have read and understand all of the information given to me in the Notice of Privacy Practices form by Above and Beyond Chiropractic Family Health Center, Ltd. (Sign and date)

 

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Explanation of Free Services

Above and Beyond Chiropractic Family Health Center, Ltd. happily extends a free consultation and examination up to 45 minutes to all new patients/ In the even that further examination is necessay, the patient will be responsible for the payment of the remainder of the examination. Treatment is not inculded in the free consultation and examination. The patient will be notified before any examination or other service is performed that requires payment. (Sign and date)

 

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