PATIENT INFORMATION
Name:________________________________________Date of Birth____________ S.S #_____________________ Today's Date:_________
Address:___________________________________City:_____________________State:_______Zip:__________E-Mail________________
Phone: (H)_____________________(W)_____________________ Referred to our office by:_______________________________________
Name of Spouse:______________________Parent/Legal Guardian_______________________Children
_________________________________
Occupation_______________________________Employer Name and Address__________________________________________________
Height:________Weight:_________Any recent gains or loss?_____ Name of nearest relative/ phone number___________________________
INSURANCE INFORMATION
Who is responsible for this account? __________________________Insured’s Name and Birth date _________________________________
Relationship to patient ___________________Insurance Co. Name and Address__________________________________________________
Group Number__________________________________________ Policy Number (ID #)
______________________________________________
ASSIGNMENT AND RELEASE
I, the undersigned certify that I (or my dependent) have insurance coverage with___________________ and assign directly to Dr. Marko 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 hereby authorize the doctor to re-
lease all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
Responsible Party Signature ___________________________________________ Relationship ______________________________Date________________
ACCIDENT INFORMATION
Is this condition due to an accident? Yes No Date of accident____________ Type of Accident (circle one) Auto Work Home Other
Was this reported? Yes No Attorney Name and Phone Number (if applicable
) ___________________________________________________
REASON FOR THIS VISIT
Reason for visit:_________________________________________ When was the first time you were aware of it?______________________
Wellness check up _______(No symptoms, I would like to be checked for Vertebral Subluxations)
How did this condition develop (what caused it)?__________________________________________________
Have you ever had the same or similar problem before? Y N Is this condition getting worse? Y N
Rate the severity of your symptoms, on a scale of 1-10 (1 being the least, 10 being most severe) ____________
Mark an X on the picture where your symptoms are
How often do you have this symptom?____________________ constant or intermittent?_________________
If you have pain, what type of pain is it? (circle one) Sharp Dull Throbbing Numbness Aching
Shooting Burning Tingling Stiffness Swelling Other______________
Does it interfere with your (circle one) Work Sleep Daily Routine Recreation Sitting Standing Walking Bending Lying Down
Have you ever had treatment for this condition before? Y N If yes, by whom / when?____________________________________________
Have you ever been to a Chiropractor before? Y N If yes, whom / when?_____________________________________________________
Please turn over
WELCOME TO DRS. MARKO FAMILY CHIROPRACTORS
Please answer the following questions to the best of your ability, and return it to the front desk.
HEALTH HISTORY
Please circle any symptom/condition which you have now, or have had in the past:
If you have a family history of any of the above, please list them here
____________________________________________
_______________________________________________________________________________________________
Are you pregnant?
Y N Due date__________ Pregnancy related symptoms?
___________________________________
Signature of patient (or guardian if minor) ___________________________________________ Date _________
Depression
Diabetes
Digestive problems
Dizziness
Ear fluid/infections
Ears ring/buzzing
Eating disorders
Emphysema
Epilepsy
Face seems flushed
Fainting
Fatigue
Fractures
Glaucoma
Goiter
Gonorrhea
Gout
Growing pains
Head seems heavy
Headaches
Hearing problems
Heart condition
Heartburn
Hepatitis
Hernia
Herniated disc
Herpes
High blood pressure
High cholesterol
Hyperactivity
Infertility
Irritability
Kidney disease
Light hurts eyes
Liver disease
Loss of balance
Measles
Memory loss
Miscarriage
Mononucleosis
Multiple Sclerosis
Mumps
Neck pain/stiffness
Nervousness/tension
Numbness
Osteoporosis
Pacemaker
Parkinson’s Disease
Pinched Nerve
Pins and needles
Pneumonia
Polio
Poor posture
PMS
Prostate problems
Prosthesis
Psychiatric disorder
Reflux
Rheumatoid Arthritis
Rheumatic Fever
Ringing in the ears
Scarlet Fever
Scoliosis
Shortness of breath
Skin disorder
Sleeping problems
Stomach problems
Stroke
Suicide attempt
Thyroid problems
Tonsillitis
Tuberculosis
Tumors/growths
Typhoid fever
Ulcers
Vaginal infections
Visual problems
Whooping Cough
A.D.H.D
Aids/HIV
Alcoholism
Allergies
Anemia
Appendicitis
Arthritis
Asthma
Back pain
Bed-wetting
Bleeding disorders
Breast conditions
Breathing problems/Sinus
Bronchitis
Cancer
Cataracts
Chemical dependency
Chest pain
Chicken Pox
Cold hands/feet
Cold sweats/fever
Colic
Colon problems
Concussion
Constipation/diarrhea
Depressed immune system
BIRTH HISTORY
Length of labor and delivery?
__________________________
Were any of the following
used for delivery?
(Please circle)
Forceps Vacuum C-section
Breech Delivery
APGAR Score__________
Breast feeding bottle feeding
EXERCISE HISTORY
(Please circle one)
None
Moderate
Daily
Heavy
What type of exercise?
__________
_________
____
WORK ACTIVITY
(Please circle one)
Sitting
Standing
Light Labor
Heavy Labor
Hours per day____________
Days per week____________
HABITS
Smoking ( Packs /day)____
Alcohol (drinks /wk.)_____
Coffee/caffeine/day______
High stress level_________
Nutrition?_______________
How many glasses of water
do you drink per day?______
Injuries/surgeries/medications Description Date
Falls /Accidents (auto or personal) ___________________________________________________________ ___________________
Head injuries______________________________________________________________________________ ___________________
Broken bones/dislocations___________________________________________________________________ ___________________
Surgeries_________________________________________________________________________________ ___________________
Medications _____________________________________________________________________________________________________