Online Chiropractic form | Bach to health chiropractor Phoenix

Patient Data

First Name *

Last Name *

Date

Email *

* Your email will NOT be shared with any 3rd parties, and is used for occasional office announcements and promotions.

Mailing Address

Address *

City *

State *

Zip *

Telephone (Work) *

Telephone (Home) *

Referred By

Age

Birth Date

Social Security#

Number of Children

Occupation

Employer

Marital Status

Spouse's Name

Spouse's Occupation

Spouse's Employer

Spouse's Health Status

Emergency Contact *

Emergency Contact Phone *

Current Complaints

Nature of Injury:

Automobile*

Work

Other

Please describe

Have you ever had same condition?

Yes

If yes, when?

List of other practitioners seen for this injury/condition

Have you ever been under chiropractic care?

Yes

If yes, please describe

Insurance Information

Name of party responsible for payment

Phone

Do you have health insurance?

Yes

Name of company

* If an auto accident, please provide:

Insurance Company Name

Contact Person

Phone

Claim #

Signatures

Name of the insured

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Patient’s signature

Date

Spouse’s or guardian’s signature

Date

Medical History

Have you been treated for any conditions in the last year?

Yes

If yes, please describe

Date of last physical exam

Is there a chance that you are pregnant?

Yes

Have you had X-rays taken?

Yes

If Yes, where?

What medications are you taking and for what conditions (Please list dosage and amounts, etc)l

What vitamins, minerals, or herbs do you currently take? (Please list for what conditions, dosage, and frequency).

Have you ever

Broken bones?

Yes

Briefly Explain

Been hospitalized?

Yes

Briefly Explain

Been in an auto accident?

Yes

Briefly Explain

Had Sprains/Strains?

Yes

Briefly Explain

Been struck unconscious?

Yes

Briefly Explain

Had surgery?

Yes

Briefly Explain

Family History

Family Members - Present and past health conditions (Example: heart disease, cancer, diabetes, arthritis, etc.)

Habits

Alcohol

None

Light

Moderate

Heavy

Coffee

None

Light

Moderate

Heavy

Tobacco

None

Light

Moderate

Heavy

Drugs

None

Light

Moderate

Heavy

Exercise

None

Light

Moderate

Heavy

Sleep

None

Light

Moderate

Heavy

Appetite

None

Light

Moderate

Heavy

Soft Drinks

None

Light

Moderate

Heavy

Water

None

Light

Moderate

Heavy

Salty Foods

None

Light

Moderate

Heavy

Sugary Foods

None

Light

Moderate

Heavy

Artificial Sweeteners

None

Light

Moderate

Heavy

Online Forms

New Patient Health History Form

Patient Data

Mailing Address

Current Complaints

Insurance Information

Signatures

Medical History

Have you ever

Family History

Habits

Have you ever suffered from

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