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New Patient Application

Corradino Chiropractic                                                                                                                            PIN#________________

 

PATIENT INFORMATION & CONDITION FORM

Patient Name: __________________________________________________________________________Today's Date: ____/____/____

Social Security Number ________________________ Birth Date: ____/____/____   Age: _____   Gender:  F   M

If you are under 18 years of age, who are your legal parents or guardian?

Father: ____________________________________________Date of Birth: ____/____/____    Phone:  (______) ________________

Mother: ___________________________________________Date of Birth: ____/____/____     Phone:  (______) ________________

Guardian: ___________________________________________Date of Birth: ____/____/____ Phone:  (______) ________________

Who do you normally live with?    Mother and Father      Father      Mother     Legal Guardian    None

Marital Status:     Married     Separated     Widowed     Single     How many children? ____________

CURRENT ADDRESS

Street__________________________________________________________________________________________________________________

City _______________________________________________________________State ________   Zip___________________________

Phone (_______) ___________________

OTHER ADDRESSES WHERE YOU RESIDE (e.g., parents' home, any other address where you regularly reside)

Street_________________________________________________________________________________________________________________

City ______________________________________________________________State ________   Zip ___________________________

 Phone (_______) ___________________

Your Occupation ____________________________________________Employer___________________________________________

Work Address _______________________________________________________________________________

Work Phone (______) ________________

Student at ______________________________________________________________________________________   

  FULL-TIME     PART-TIME

Name of Spouse _____________________________________________________________Spouse's Date of Birth ____/____/____

Spouse's Occupation ____________________________________________Spouse's Employer _____________________________

Spouse's Work Address _____________________________________________________________________

Work Phone (______) ________________

Spouse is a student at __________________________________________________________________________   

  FULL-TIME     PART-TIME

Who should we contact in the event of an emergency?   ___________________________________________   

Phone (______) ________________

Address of contact person _______________________________________________________________________________________

How did you learn about us? ______________________________________________________________________

Is your condition or injury due to an accident or work-related cause?     YES     NO   Please check ALL that apply.

Did the condition or injury result from automobile accident?     YES     NO

Did it result from a work-related accident or cause?     YES     NO (briefly describe): ___________________________

If the condition did not result from an automobile accident or relate to your work, where did the accident occur? ______________________________________________________________________________________________________________________________

Approximately, when did your injury or condition occur?  ____/____/_____

 

Describe your condition, symptoms, or the purpose of this appointment: ______________________________________________

__________________________________________________________________________________________________________________________________

Have you ever had the same or similar condition?     YES     NO     If yes, when and describe: _________________________________________________________________________________________________________________________________________________________________

 

Please indicate any other healthcare providers who you've seen for this injury or condition, and when you last saw them.

     Name: ___________________________________   Type of Practice:  ______________________________  

Date of Last Visit:  ____/____/_____

     Name: ___________________________________   Type of Practice:  ______________________________  

Date of Last Visit:  ____/____/_____

     Name: ___________________________________   Type of Practice:  ______________________________  

Date of Last Visit:  ____/____/_____

 

Date of last physical examination? ______________________________________________

What surgery have you had? ____________________________________________________________  

When? _______________________________

Serious illnesses or conditions? __________________________________________________________  

 When? _______________________________

Have you been treated for any health condition by a physician in the last year? YES   NO Describe: _______________________________________________________________________________________________________________

What medications or drugs are you taking?________________________________________________________________________

Have you ever suffered from:

                  Dizziness                                             Arthritis                                                   Digestive Disorders

                  Backaches                                           Headaches                                               Nervousness

                  Heart Trouble                                      Numbness                                                Sinus Trouble

                  Diabetes                                              Asthma                                                     Anemia

                  Hernia                                                  Neuritis                                                 Cancer

WOMEN ONLY:  Are you pregnant or is there any possibility you may be pregnant?    YES    NO 

Do you have health insurance?     YES     NO     Not Sure   

Company: ___________________________________________________

Full Name of Policy Holder: ___________________________________   Policy Holder's Date of Birth ____/____/_____   Does the policy holder have the insurance through his/her employer?    YES     NO  

If yes, who is the employer? _____________________________________

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I understand and agree that health and accident insurance policies are an arrangement between my insurance company and myself -- not between my insurance company and this office.  I agree to pay my estimated patient responsibility and further understand that the estimated responsibility is neither a guarantee of payment by my insurance company, nor necessarily an accurate reflection of my actual responsibility as determined by my insurance company upon processing of my claims.  In the event that my insurance company does not pay on my charges at the estimated rate or within a reasonable period of time, upon request of this office I will immediately pay the balance owing on my account unless otherwise agreed to in writing. I understand that an interest charge may appear on all accounts over 90 days.  I further understand and agree, that if this office must take any action to collect an outstanding balance on my account, I will be responsible for payment and will reimburse this office for all costs of such collection efforts, including, but not limited to, all court costs and attorney fees.

 

I authorize this office to release any medical information relating to my treatment to any insurance companies which may be responsible for paying benefits to me, and to any attorney s who may be representing me due to my condition, and to complete any usual and customary reports and forms at no charge to assist in collecting from my insurance companies, attorneys, or other payers.

 

I have read, understood, and agree to the foregoing.  The information which I have provided is true and complete to the best of my knowledge.

 

Patient's Signature: __________________________________________________________________   Date: ____/____/_____