Rhodes Chiropractic Case History/Patient Information

The following information is needed in order to better serve you. Please complete all questions.

Today’s Date *

Acct. #

PATIENT INFORMATION

First Name *

Last Name *

Cell Phone *

Email *

Address

City

State

Postal code

Date of birth

Marital Status

Number of Children

Employer

Occupation

Employer Address

City

State

Postal Code

SSS number

Name of Spouse or Parent

Spouse Employed By

Occupation

Employer Address

City

State

Postal Code

Emergency Contact

Phone

Referred to our office by

MAJOR COMPLAINTS

Is your condition due to an accident?

Yes

Date Symptoms appeared or accident happened

Have you ever had the same or similar condition?

Yes

If yes, when and describe

Type of accident

Auto

Work/On Job

At Home

Other

Have you ever been in an auto accident?

Past Year

Past 5 Years

Over 5 Years

Never

Insurance

Name of Primary Insurance Company

Name of Secondary Insurance Company

How will payments be made

Cash

Check

Credit Card

PAST MEDICAL HISTORY

Do you have a history of stroke or hypertension (high blood pressure)?

Have you had any major illnesses, injuries, falls, auto accidents or surgeries? Women, please include information about childbirth (include dates)

Have you been treated for any health condition by a physician in the last year?

Yes

If yes, describe

Please list any other health problems you have, no matter how insignificant they may be

AUTHORIZATION AND RELEASE

I authorize payment of insurance benefits directly to the chiropractor or chiropractic office physicians to secure the payment of benefits. I understand that I am responsible for all costs of chiropractic care, regardless of insurance coverage. I have received a current copy of Rhodes Chiropractic financial policy.

The patient understands and agrees to allow this chiropractic office to use their Patient Health Information for the purpose of treatment, payment, healthcare operations, and coordination of care. We want you to know how your Patient Health Information is going to be used in this office and your rights concerning those records. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent. If there is anyone you do not want to receive your medical records, please inform our office.

I authorize Rhodes Chiropractic to release any and all medical records, x-ray reports, and account information to the following person(s)

Patient's Signature

Clear

Guardian's Signature Authorizing Care

Clear

Date

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