Today’s Date: ______________ Welcome! Chiropractic Wellness Center  Denise Primavera, DC  4019 Bethlehem Pike, Telford, PA 18969 / Phone: 215-723-7900 / Fax: 215-723-4481 NEW PATIENT INFORMATION Patient Name: ___________________________________________________________ (Last Name) (First Name) (Middle Name) SSN: _____________________ Date of Birth: __________________ Age: __________ Sex (circle): male/female Status (circle): Single/Married/Divorced/Widowed/Partnered Home Address: __________________________________________________________ (Street) (City) (State) (Zip) Home Phone: (____) __________________ Cell Phone: (____) ___________________ Employer: ________________________________ Occupation: __________________ Employer Location: _________________________ Work Phone: (____) ____________ Email Address: __________________________________________________________ Emergency Contact: ______________________________________________________ (Name) (Phone #) How did you hear about our practice? ________________________________________ Have you ever been to a chiropractor before (circle)? No / Yes Is your condition due to an accident (circle)? No / Yes If yes, accident date: _________ If yes, please circle: Work / Auto / Home / Other: ______________________________ INSURANCE INFORMATION Assignment & Release: I certify that I, and/or my dependents, have insurance coverage with the below stated insurance company and assign directly to the Chiropractic Wellness Center all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. Drs. Primavera/Coforio may use my healthcare information and may disclose such information to the below-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below. Insurance Co: ________________________________ Subscriber’s Date of Birth: ___________ Subscriber’s Name: ____________________________ Subscriber’s SSN: __________________ Relationship to Patient: Self / Spouse / Parent / Other: _________________________________ Signature: __________________________________________ Date: __________________ (Patient/Parent/Guardian/Personal Representative) Please Print Name: _____________________________________________________________ Patient Name: ________________________________ DOB: ____________ Date: __________ Chiropractic Wellness Center  Denise Primavera, DC  4019 Bethlehem Pike, Telford, PA 18969 / Phone: 215-723-7900 / Fax: 215-723-4481 PATIENT CONDITION Please describe your reason for this visit: __________________________________________ When did your symptoms begin? _________________________________________________ Is your condition getting worse? No / Yes Is this the first episode: No / Yes Is your pain (circle one): Constant / Frequent / Occasional / Depends on activity / None Please check all that apply to describe your pain:     Sharp Dull Throbbing Numbness     Aching Shooting Burning Tingling     Cramping Stiffness Swelling Other: _______________ Please mark on the figure the location of your symptoms and circle your level of pain: Does your condition interfere with any of the following activities (check all that apply)?  Daily Routine  Work  Sleep  Recreation  Walking  Sitting  Standing  Lying Down  Stair Climbing  Bending  Lifting  Other: __________ Have you seen any of the following for this condition (check all that apply)?  Medical Doctor  Physical Therapist  Chiropractor  Massage Therapist  Acupuncturist  None  Other: ________________________ Have you had any imaging (x-ray, MRI, CT scan, ultrasound, etc) of the area of complaint? No / Yes If yes, what/when: ___________________________________ Have you had any recent changes in your weight without a change in diet? No / Yes Have you had any changes or problem urinating or having a bowel movement? No / Yes Does your pain wake you up at night? No / Yes Do you have a pacemaker? No / Yes Women: Are you pregnant? No / Yes, Due Date: ______________________________ Date of Last Menstrual Period: ______________ Patient Name: ________________________________ DOB: ____________ Date: __________ Chiropractic Wellness Center  Denise Primavera, DC  4019 Bethlehem Pike, Telford, PA 18969 / Phone: 215-723-7900 / Fax: 215-723-4481 PATIENT HEALTH HISTORY Patient current height: _____________ Patient current weight: ___________ lbs. Date of last physical exam: _____________ Date of last blood work: ____________ Please check all that apply and specify date/age or how long you’ve had condition: Condition Alcoholism Anemia Anorexia/Bulemia Anxiety Appendicitis Arthritis Asthma Back/Neck condition Bipolar disorder Bleeding disorder Cancer/Tumor Cataracts Chemical dependency Chicken Pox Cold sores COPD Depression Diabetes Dislocation(s) Dizziness/Fainting Ear pain/ringing Emphysema Epilepsy/Seizures Eye Condition Fibromyalgia Fractures Gall bladder problems Glaucoma Gout Headaches/Migraines Head trauma/injury Heart/Vascular disease Hepatitis Herniated disc High blood pressure High cholesterol Yes, I’ve had this Date/Age of Diagnosis Condition Yes, I’ve had this Date/Age of Diagnosis Kidney Problems Liver problems Lung problems Lupus Lyme disease Measles/Mumps Miscarriage Mononucleosis Multiple Sclerosis Neurologic Condition Osteoporosis or Osteopenia Parkinson’s Pinched nerve PMS/Menstrual Pneumonia Polio Prostate problems Prosthesis Psychiatric care Recent fever/flu Rheumatic fever Scarlet fever Scoliosis Sinus problems Skin disorder STDs/AIDS/HIV Stomach problems Stroke Thyroid problems Tonsillitis Tuberculosis Ulcers Urinary tract infections Vaginal infections Whooping cough I have not had any of these health problems  Please list any health problems/concerns that are not listed: ____________________________ Patient Name: ________________________________ DOB: ____________ Date: __________ Chiropractic Wellness Center  Denise Primavera, DC  4019 Bethlehem Pike, Telford, PA 18969 / Phone: 215-723-7900 / Fax: 215-723-4481 PATIENT HEALTH HISTORY CONTINUED Name of Primary Care Physician: _______________________ Ph #: _______________ Primary Care Physician Address: ____________________________________________ Please list any surgeries you have had and date performed: ______________________ _______________________________________________________________________ Do you have any allergies? No / Yes If yes, please specify: ______________________ Are you taking any prescription or over-the-counter medications? Yes / No If YES, please list any medications you are taking and why: Medication Name/Dose Started (Date/Year) For What Condition Please list any supplements/herbs you take: ___________________________________ _______________________________________________________________________ Do you smoke? No / Yes If yes, how much? _____________________________ Do you exercise? No , Some , Moderate , Heavy  Type: __________________ Do you drink coffee? No / Yes If yes, how much? _____________________________ Do you drink alcohol? No / Yes Is your stress level: If yes, how much? ____________________________ None , Mild , Moderate , High  Is your work activity: Sitting , Standing , Light Labor , Heavy Labor  Are you interested in nutritional counseling? No / Yes FAMILY HEALTH HISTORY Check any disorders that close family members (parents, siblings, or grandparents) have had : Heart Disease/Stroke Diabetes Kidney Disease Liver Disease Lung Disease Cancer Other No No No No No No No / / / / / / / Yes Yes Yes Yes Yes Yes Yes If If If If If If If Yes, Yes, Yes, Yes, Yes, Yes, Yes, who: who: who: who: who: who: who: _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________