open_vision_design (2K)
SITE DESIGN

* If booking online, we will contact you with a confirmed appointment time *
Emergency
Name:
Email:
Address:
State:
Zip:
Home Phone #:
Work Phone #:
Cell Phone #:
Date of Birth:
Age:
Insurance Company Name:
Employer:
Occupation:
Work Address:

Married

Single
Spouse's Name:
Spouse's Date of Birth:
Who referred you to us?

List present complaints, injuries and duration:
1-
2-
3-

Have you had Chiropractic care before?
Yes No
Do you have health insurance? Yes No
Is it possible you are pregnant? Yes No

Are you here for care because of :
An auto accident
An on the job injury
Other
Please explain

Date of your last physical examination
Reason
Name of Doctor and Approx Date of Last Visit:
Are you on Medicare? Yes No
Date injured
Do you have an attorney? Yes No

Please list all accidents, falls, broken bones, injuries, surgeries, major illnesses
TYPE           DATE          DESCRIBE/COMMENTS

Are you presently taking any medication?
NAME OF DRUG          ATM         DESCRIBE/COMMENTS