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Patient History
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Name:
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Date of Birth
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Height
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Weight
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Referring Provider
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What is bothering you?
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Which Areas of the body are effected?
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INTENSITY
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% of the Day?
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SENSATION?
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Severity, Indicate the number that best describes your pain level:
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Duration/Timing/Aggravating & Alleviating Factors
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How long have you had your symptoms (in months and years)?
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What caused the symptoms to start?
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How often do you have your symptoms?
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What makes your symptoms worse?
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What makes your symptoms better?
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What treatments have you tried to treat your symptoms?
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if you selected other. What other treatments have you tried?
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What medications have you tried to treat your symptoms?
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Initial Treatment Goal
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What would you like to achieve from treatment?
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What treatment are you interested in trying?
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Allergies (please include reaction)
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Medications (Include all over the counter and supplements)
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Medication name, strength, and how often.
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Medication name, strength, and how often.
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Medication name, strength, and how often.
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Medication name, strength, and how often.
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Medication name, strength, and how often.
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Medication name, strength, and how often.
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Medication name, strength, and how often.
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Medication name, strength, and how often.
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Have you ever had previous chiropractic care?
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Type of adjustment preferred:
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If other type of adjustment, please describe.
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Therapies that have helped in the past:
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Age of your Mattress?
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Sleep position
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Activity:
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Review of symptoms: Have you experienced any of the following in the past month? Check all that apply
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Constitutional
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Heent:
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Cardiovascular
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Respitory
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Abdominal
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Genitourinary
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Neurologic
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Psychiatric
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Integumentary
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Musculoskeletal
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Endocrine
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Heme/Lymph
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Allergic/Immune
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Medical History
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Check box if you have a personal history of any of the following
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Other personal medical history we should know
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Do you have a demand pacemaker, cardiac defibrillator or implantable simulator?Yes / No
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If yes please explain.
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Have you had any diagnostic studies?
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If Yes. Please list area and date:
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Past Surgical History: (procedure and date)
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Family History
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Check all that apply Significant for.
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Maternal:
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Cause of death.
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Paternal.
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Cause of death.
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Number of Siblings:
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Significant Medical Illness:
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WOMEN: Are you currently pregnant or plan on becoming pregnant? Yes / No
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Social History
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Current history of drug use, including prescription narcotics? Yes / No
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If Yes, please explain:
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Current history of alcohol use? Yes / No
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How many drinks per day? OR the year you quit
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Current or history of tobacco use? Yes / No
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Number of packs per day? OR year you quit.
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Current history of caffeine use? Yes / No
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Drinks per day? OR year quit.
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Present living situation?
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Present Living situation status?
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Education
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Highest level of education?
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Occupation
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Employer
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Work Status:
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I understand that providing incorrect information can be dangerous to my health.
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It is my responsibility to inform the doctor's office of any changes in my medical status.
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I authorize the healthcare staff to preform the necessary healthcare services I may need.
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To the best of my knowledge, the questions on this form have been accurately answered. Type Name.
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New Free Draw
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General Information: Patient
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Last Name
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First Name
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Address
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City
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State
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Zip Code
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Home phone
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Cell Phone
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Work Phone
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Email Address
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Out of State Address
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Date of Birth
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Age
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Social Security Number
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Sex
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Appointment reminders:
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Emergency Contact Name:
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Emergency Contact phone:
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Emergency Contact Relationship
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Whom may we thank for referring you to us?
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Will you be using insurance today?
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Insurance Information
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PRIMARY Insurance Company Name:
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Membership Number:
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Group Number:
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SECONDARY Insurance Company Name:
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Membership Number:
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Group Number:
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Auto Accident/Workers' Compensation Only
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Insurance Company Name:
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Claim Number:
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Adjustor's Name:
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Phone Number:
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Attorney's Name:
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Phone Number:
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Preferred Language:
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Records Request
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Patient Name
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Date of Birth
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Address
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City
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State
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Zip Code
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Home phone
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Work Phone:
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* The above listed patient authorizes the following health care facility to make healthcare disclosure*
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Facility Name:
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Facility Phone:
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Facility Address:
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City
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State
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Zip Code
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Dates and type of information to disclose:
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2 years from the date last seen Yes / No
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Dates other:
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Specific information requested:
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Reason for Disclosure:
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Other:
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Restrictions: Only medical records originated through this healthcare facility will be copied unless otherwise requested.
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This authorization is valid only for the release of medical information dated prior to and including:
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The date on this authorization unless other dates are specified.
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I understand the information in my health record may include information relating to sexually transmitted diseases.
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Including acquired immuno deficiency syndrome (AIDS), or human immuno deficiency virus (HIV).
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It may also include information about behavioral or mental health services, and treatment for drug and alcohol abuse.
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This informationmay be disclosed and used by the following individual or organization.
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Release to: Synergy Health Center Please Mail Records to 13020 Livingston Rd. Suite 14, Naples, FL 34105 FAX: 239-263-7492
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I understand I may revoke this authorization at any time.
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I understand that if I choose to revoke this authorization I must do so in writing and present my written revocation:
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To the Health Management Department. I understand revocation will not apply to information that has been already released.
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I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to..
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Contest my claim under my policy.
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Unless revokedthis authorization will expire on the following date, event, or condition:
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If I fail to specify an expiration date, event, or condition, this authorization will expire in 1 year from the date signed.
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I understand that authorizing the disclosure of this health information is voluntary.
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I can refuse to sign this authorization. I need not sign this form in order to assure treatment.
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I understandthat I may inspect or obtain a copy of the information used or unauthorized re-disclosure of the information....
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The information may not be protected by the by the federal confidentiality rules.
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If I have questions about disclosure of my information, I can contact the authorized individual/organization making disclosure.
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I have read the above fore going Authorization of Release of Information.
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I hereby acknowledge that I am familiar with and fully understand the terms and conditions of this authorization.
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Print Name of Authorized Representative
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Signature of Patient/Parent/Guardian or Authorized Representative
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Sign:
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