Today's Date ____________________ Time_________________________

Patient Name__________________________________________________________________________
                                           Title                        First                                        Middle                                    Last

Address______________________________________________________________________________
                                                  Street                                                     City                                        State                       Zip Code

Home Phone _______________________  Social Security Number_____________________ Male   Or   Female

Birth date ______________ Age _________

Marital Status     Single___   Married___    Divorced ___ Widowed___

Employer ______________________________Work Phone ________________ Date Hired ________

Patient’s Height ____________Weight _____________ Shoe Size _______ Right  or  Left   Handed

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Responsible Party Information               

Patient is responsible party    Yes    No                          Patient is My_____________________

Responsible Person’s Name______________________________________________________________
                                                     Title                                 First                                 Middle                                    Last

Address_______________________________________________________________________________
                                            Street                                                     City                                        State                                Zip Code

Home Phone Number _____________________Social Security Number ______________________

Male or Female            Birth date _______________

Employer_______________________________ Work Phone ___________________

Work Address__________________________________________________________________________
                                             Street                                                     City                                        State                                Zip Code

Primary Insurance __________________________Secondary Insurance___________________________

Who Do We Thank for referring you to our office?_____________________________________________

IS THIS A WORKMAN’S COMPENSATION INJURY       YES            NO      If yes please inform Staff

I authorize any holder of medical or other information about me to release to my insurance company or to the social security administration and healthcare financing administration or it’s intermediaries or carrier, any information for this or a related Medicare or other insurance claim.  I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits to my physician.  Regulations pertaining to medical assignment of benefits apply.  I understand that I am financially responsible to the physician for charges not covered by this agreement or that are above the usual and customary.  All  deductibles, Co-pays and applied percentages are due on the day of treatment.  I have read or had read to me the above information and understand my responsibilities.

Date_____________________________ Signed________________________________________________

Primary Care Physician ___________________________________Last Seen________________________

Past Medical History         Circle the ones that apply

ARE YOU PREGNANT                            YES         NO

Past Surgical History

Please list any surgeries you have had_________________________________________________________

________________________________________________________________________________________

Have you ever been hospitalized?    Yes    No       If yes for what reason_____________________________

Medications______________________________________________________________________________

Drug Allergies____________________________________________________________________________

Family History                      Circle those that apply                M=Mother   F=Father     B=Brother   S=Sister

Arthritis ( M--F--B--S )            Cancer ( M-- F--B--S )      Diabetes ( M-- F--B--S )     Gout ( M-- F--B--S)    

Glaucoma (M-- F--B--S )          Heart Disease ( M-- F--B--S )           Heart Attack (  M-- F-- B-- S)

High Blood pressure ( M -- F--B--S )       Stroke ( M--F--B--S)             Thyroid Disease   ( M-- F--B--S)

Mother Deceased   Y   N            Father Deceased   Y    N      

Social History

Tobacco use    Yes   No                If Yes   How much do you smoke and for how many Years____________

If you chew, How much and for how many years________________________________________________

Do you drink alcohol   Yes    No    If yes, What do you drink and amount consumed per day____________

Do you use drugs     Yes      No                If yes, What drugs are you using___________________________

________________________________________________________________________________________ 

What are the physical requirements of your job?   

Standing---Walking--- Lifting---Concrete Surface--Steel toe-

Do you work out or run?   Yes   No      If yes, How often________________________________________

Review Of Systems       Please circle the items in each category that apply

Head, Eyes

Double Vision                Infection                       Seasonal Allergies             Dizziness

Fainting                 Headaches                            Migraine Headaches         Cataracts

Ears, Nose, And Throat       Please circle the items in each category that apply

Nose Bleeds            Ringing in the ears           Trouble Swallowing             Hearing Loss

Respiratory       Please circle the items in each category that apply

Emphysema           Asthma               Bronchitis                Shortness of Breath

Cardiovascular       Please circle the items in each category that apply

Palpitations     High Blood Pressure     Murmur      Congestive Heart Failure

Gastrointestinal       Please circle the items in each category that apply

Hiatal Hernia       Hepatitis A   B   C       Reflux      Gastric Ulcer        Diverticulitis

Genitourinary       Please circle the items in each category that apply

Trouble Urinating                Painful Urination

Musculoskeletal       Please circle the items in each category that apply

Back Pain         Joint Pain        Muscle Pain        Heel Pain

Dermatological       Please circle the items in each category that apply

Thick toenails       painful sores         infected/ingrown toenails

Neurological       Please circle the items in each category that apply

Stroke                    Tremor                   Seizures                 Burning Feet

Endocrine       Please circle the items in each category that apply

Type 1 diabetes                      Type 2 Diabetes                 Thyroid Disorder

Please use the space provided to describe your reason for today’s visit: __________________________

______________________________________________________________________________________

______________________________________________________________________________________

Has this condition been treated another doctor’s office Yes   or   No.  

If yes Which Doctor________________