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maxwellrymer
2017-02-01T13:02:52-06:00
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1. Primary Patient Information
Many of the items on this form are required. If the areas are not applicable, please fill in "none" as your answer!
Name
*
First
Middle
Last
Email
*
Gender
*
Gender
Male
Female
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
US Minor Outlying Islands
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Primary Phone Number
*
Cell Phone (if Different)
Preferred Method of Contact
*
-----
Text
Phone Call
Email
Employer Name
*
Occupation
*
Age
*
Date of Birth
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
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23
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26
27
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29
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31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
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1945
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1932
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1930
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1928
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1926
1925
1924
1923
1922
1921
1920
Marital Status
*
-----
Single
Married
Engaged
Divorced
Widowed
Spouse Name
Referred By
Number of Children
Children Age, Name & Gender
2. Healthcare Concerns
Concern #1
*
Severity (Scale 1-10)
*
----
1
2
3
4
5
6
7
8
9
10
When did it begin?
*
Had Before (When)
*
Did it begin with an Injury?
*
------
Yes
No
How frequent are the symptoms?
*
-----
Constant
Intermittent
Concern #2
Severity (Scale 1-10)
----
1
2
3
4
5
6
7
8
9
10
When did it begin?
Had Before (When)
Did it begin with an Injury?
------
Yes
No
How frequent are the symptoms?
-----
Constant
Intermittent
Concern #3
Severity (Scale 1-10)
----
1
2
3
4
5
6
7
8
9
10
When did it begin?
Had Before (When)
Did it begin with an Injury?
------
Yes
No
How frequent are the symptoms?
-----
Constant
Intermittent
Concern #4
Severity (Scale 1-10)
----
1
2
3
4
5
6
7
8
9
10
When did it begin?
Had Before (When)
Did it begin with an Injury?
------
Yes
No
How frequent are the symptoms?
-----
Constant
Intermittent
Concern #5
Severity (Scale 1-10)
----
1
2
3
4
5
6
7
8
9
10
When did it begin?
Had Before (When)
Did it begin with an Injury?
------
Yes
No
How frequent are the symptoms?
-----
Constant
Intermittent
Seen other doctors for these conditions?
*
-----
Yes
No
Chiropractor?
*
-----
Yes
No
Medical Doctor?
*
-----
Yes
No
3. Medical History
List all Surgical Operations & Years
*
List all Prescription & Over-Counter Medications
*
When was your last auto accident?
Have you had previous Chiropractic care?
*
-----
Yes
No
If so, Dr. Name and Date Seen?
Have you ever been knocked unconscious?
*
-----
Yes
No
Have you ever fractured a bone?
*
-----
Yes
No
If knocked unconscious or fractured a bone, please describe
Other Trauma?
Other Problems?
4. Insurance Information
Primary Insurance Carrier
*
Name of Insured
*
Insured Birthdate
*
Month
1
2
3
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9
10
11
12
Day
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31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
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1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
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1941
1940
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1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Insured Member ID
*
Secondary Insurance Carrier
Secondary Name of Insured
Secondary Insured Birthdate
Month
1
2
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7
8
9
10
11
12
Day
1
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11
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13
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19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Secondary Insured Member ID
Contact in Case of Emergency
*
Emergency Contact Phone Number
*
Social Security Number
5. Family Health History
Current Problems You Have
*
Dizziness
TMJ
Thyroid Problems
Menstrual Disorder
Irritable Bowel
Hip Pain
Lupus
Knee Pain
Gastric Reflux
Headaches
Neck Pain
Asthma
Heart Disorders
Sciatica
Leg Pain
Fibromyalgia
Nervousness
Bladder Problems
Vertigo
Migraines
Ulcers
Stomach Disorders
Numbness In Legs
Liver Disease
Chest Pain
Epilepsy
Chronic Sinus
Ear Infections
Anxiety
Numbness in Arms
Kidney Problems
Numbness in Feet
Shoulder Pain
Arm Pain
Disc Problems
Nausea
Throat Issues
Numbness in Hands
Mid Back Pain
Low Back Pain
Chronic Fatigue
ADD/ADHD
Infertility
None
Other Problems
Current Conditions You Have Had/ Have Now
*
Stroke
Spinal Bone Fracture
Cancer
Scoliosis
Heart Disease
Diabetes
Spinal Surgery
Seizures
None
6. Social History
Smoking
*
None
Cigars
Pipes
Cigarettes
How Often?
Daily
Weekends
Occasionally
Never
Exercise | How Often?
*
Daily
Weekends
Occasionally
Never
Hobbies - Recreational Activities - Exercise
How does your present problem affect the following?
What daily activities are being restricted by your health issues?
*
Carrying/Lifting Groceries
Laundry
Walking
Shaving
Static Standing
Sitting to Standing
Driving
Dishes
Bathing
Climbing Stairs
Extended Computer Use
Reading Concentration
Sexual Activity
Pet Care
Garbage
Sweeping/Vacuuming
Sleep
Yard Work
Lifting Children
Dressing
Static Sitting
None
Please Select the Number that Best Describes the Question Being Asked.
Select pain level for each issue you are experiencing on a scale of "0-10". With 0 being "No Pain" to 10 being "Worst Possible Pain".
Issue #1
*
What is you pain RIGHT NOW?
*
-----
0
1
2
3
4
5
6
7
8
9
10
What is your TYPICAL or AVERAGE pain?
*
-----
0
1
2
3
4
5
6
7
8
9
10
What is your pain level AT ITS BEST (how close to "0" does your pain get at its best)?
*
-----
0
1
2
3
4
5
6
7
8
9
10
What is your pain level AT ITS WORST (how close to "10" does your pain get at its worst)?
*
-----
0
1
2
3
4
5
6
7
8
9
10
Issue #2
What is you pain RIGHT NOW?
-----
0
1
2
3
4
5
6
7
8
9
10
What is your TYPICAL or AVERAGE pain?
-----
0
1
2
3
4
5
6
7
8
9
10
What is your pain level AT ITS BEST (how close to "0" does your pain get at its best)?
-----
0
1
2
3
4
5
6
7
8
9
10
What is your pain level AT ITS WORST (how close to "10" does your pain get at its worst)?
-----
0
1
2
3
4
5
6
7
8
9
10
Issue #3
What is you pain RIGHT NOW?
-----
0
1
2
3
4
5
6
7
8
9
10
What is your TYPICAL or AVERAGE pain?
-----
0
1
2
3
4
5
6
7
8
9
10
What is your pain level AT ITS BEST (how close to "0" does your pain get at its best)?
-----
0
1
2
3
4
5
6
7
8
9
10
What is your pain level AT ITS WORST (how close to "10" does your pain get at its worst)?
-----
0
1
2
3
4
5
6
7
8
9
10
Other Comments
Comments
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