Crockett Chiropractic Patient Information Please Print Name Date: _____________ Address City State Zip Male Female Married Single Widowed Divorced Separated Primary phone #: ______________ Secondary phone #: Birthday E-mail Address Employer Occupation #years Business Address City State Zip Spouse or Parent’s Name Phone Emergency Contact Phone Relation Whom may we thank for referring you to us? Name of local primary Physician May we contact them? SYMPTOMS Main complaints? ______ _____________ How often? When did it start? Getting worse? What activity bothers it the most? When is it at its best? When is it at its worst? Rate the pain (0 is pain free - 10 is unbearable pain) 1 2 3 4 5 Other Chiropractors? Positive experience? Health History-Please circle all that apply AIDS/HIV Breast Lump Emphysema Hepatitis Migraines Pacemaker Tuberculosis Chronic Fatigue Allergy Shots Bronchitis Epilepsy Hernia Miscarriage Pneumonia Tumors High Blood Pressure Anemia Bulimia Fractures Herniated Disc Mono Prostate Typhoid Fibromyalgia ___________________ Getting better? 6 7 8 9 10 Anorexia Appendicitis Arthritis Asthma Bleeding Cancer Cataracts Chicken Pox Depression Diabetes Glaucoma Goiter Gonorrhea Gout Heart dx Herpes High Cholesterol Kidney dx Liver dx Measles M.S. Mumps Osteoporosis Parkinson’s Polio Prosthesis Implants Rheumatoid Stroke Thyroid Tonsillitis Ulcers V.D. Whooping Cough Other_______________________________________________________________________________ Women: How many children do you have? ____ ______ Are you pregnant? _________ Nursing?______________ Date of last Menstrual Cycle Taking Birth Control Pills? Previous Surgeries and Dates? List ALL Medications you are currently taking What kind of exercise do you do? What supplements do you take? How much do you smoke per day? Drink per week? *Cancellations must be made within 24 hour notice or you will be charged for an office visit. The $25 fee will be waived if you reschedule your appointment. *Massage appointments must be prepaid. Cancellations must be made within 24 hour notice or you will be charged a $25 cancellation fee *All above questions have been answered accurately, and I understand that giving incorrect information can be dangerous. PI Cases: I authorize-this office to release any information pertaining to my treatment to third party payers or other health care providers. I authorize payment of medical benefits directly to this office. I further understand that payment may be less than the actual cost of services and I will be responsible for any outstanding amount owed this office. *By signing below, the patient gives the doctor permission and authority to care for him/her in accordance with recognized and acceptable chiropractic analytical and corrective procedures including massage therapy. Parent (for minor) Patient Signature: Date: