Jacksonchiropracticpa@1 - New Patient Registration

New Patient Registration
Patient Information
Date

MonthDayYear
Date
SS / HIC / Patient ID #
Patient Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Sex
Age
Birthdate

MonthDayYear
Date
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Best time and place to reach you
Marital Status

Partnered, for how many years:
Patient Employer / School
Occupation
Employer/School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer/School Phone
Please enter a valid phone number.Format: (000) 000-0000.
Spouse's Name
Birthdate

MonthDayYear
Date
SS#
Spouse's Employer
Whom may we thank for referring you?
Insurance Information
Who is responsible for this account?
Relationship to Patient
Insurance Company
Group #
Is patient covered by additional insurance?
Subscriber's Name
Birthdate

MonthDayYear
Date
SS#
Relationship to Patient
Insurance Company
Group #
ASSIGNMENT AND RELEASE

I certify that I, and/or my dependent(s), have insurance coverage with Name of Insurance Company(ies) and assign directly to Dr. Type a label all insurance benefits. If any, otherwise to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits of the benefits payable for related services. This concept will end when my current treatment plan is completed or one year from the date signed below.
Signature of Patient, Parent, Guardian or Personal Representative
Date

MonthDayYear
Date
Please print name of Patient, Parent, Guardian or Personal Representative
Relationship to Patient
In case of Emergency, Contact
Name
Relationship
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Is condition due to an accident?
Date of Accident

MonthDayYear
Date
Type of accident

Other
To whom have you made a report of your accident?

Other
Reason for Visit
When did your symptoms appear?
Is this condition getting progressively worse?
Date the severity of your pain on a scale from 1 (least pain) to 10 (severe pain)
Mark an X on the picture where you continue to have pain, numbness, or tingling
Type of Pain

Other
How often do you have this pain?
Is it constant or does it come and go?
Does it interfere with your
Activities or movements that are painful to perform:
What treatment have you already received for your condition?

Other
Name and address of other doctor(s) who have treated you for your condition
Last Physical Exam

MonthDayYear
Date
Last Dental X-ray

MonthDayYear
Date
Last Spinal Exam

MonthDayYear
Date
Last Spinal X-ray

MonthDayYear
Date
Last MRI, CT-Scan, Bone Scan

MonthDayYear
Date
Last Chest X-ray

MonthDayYear
Date
Last Blood Test

MonthDayYear
Date
Last Urine Test

MonthDayYear
Date
Place a mark on "Yes" or "No" to indicate if you have had any of the following:
AIDS / HIV
Alcoholism
Allergy Shots
Anemia
Anorexia
Appendicitis
Arthritis
Asthma
Bleeding Disorders
Breast Lumps
Bronchitis
Bulimia
Cancer
Cataracts
Chemical Dependency
Chicken Pox
Diabetes
Emphysema
Epilepsy
Fractures
Glaucoma
Goiter
Gonorrhea
Gout
Heart Disease
Hepatitis
Hernia
Herniated Disk
Herpes
High Blood Pressure
High Cholesterol
Kidney Disease
Liver Disease
Measles
Migraine Headaches
Miscarriage
Mononucleosis
Multiple Sclerosis
Mumps
Osteoporosis
Pacemaker
Parkinson's Disease
Pinched Nerve
Pneumonia
Polio
Prostate Problem
Prosthesis
Psychiatric Care
Rheumatoid Arthritis
Rheumatic Fever
Scarlet Fever
Sexually Transmitted Disease
Stroke
Suicide Attempt
Thyroid Problems
Tonsilitis
Tuberculosis
Tumors, Growth
Typhoid Fever
Ulcers
Vaginal Infections
Whooping Cough
Other
Exercise
Work Activity
Habits
Smoking: Packs/Day
Alcohol: Drinks/Week
Coffee: Cups/Day
Stress: Reason
Are you pregnant?

Yes, due date:

Injuries/Surgeries you have had

Rows	Description	Date
Falls
Head Injuries
Broken Bones
Dislocations
Surgeries

Pharmacy Name
Pharmacy Phone
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty:

New Patient Registration

Patient Information

Insurance Information

In case of Emergency, Contact

Place a mark on "Yes" or "No" to indicate if you have had any of the following: