A&W Family Chiropractic - Chiropractor In Marietta, GA, USA

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New Patient Paperwork

Confidential Patient Health Record Today’s Date:____/_____/________

How did you hear about us? ÿ Family ________________ ÿ Friend ___________________ ÿ Co-Worker _________________

ÿ Close to home/work ÿ Dr. ______________ ÿ Yellow pages ÿ Drove by ÿ Hospital ÿ Insurance Plan

Personal Information

Title: ÿ Mr. ÿ Ms. ÿ Mrs.

Last:__________________________ First:___________________________ Middle: ____________________________ Suffix: ÿ Jr ÿ Sr ÿ II ÿ III

Birth Date: ____ /____/_______ Age:______ Sex: Male / Female SSN: ______________________

Marital Status: ÿ Single ÿ Married ÿ Widowed ÿ Divorced ÿ Separated

Address: ______________________________________________________________________________Apt # ______

City: __________________ State: ______ Zip: _________ Country: __________________ County: _____________

Home Phone: (_______) _______-_________ ext ______ Work Phone: (_______) _______-_________ ext ______

Cell Phone: (_______) _______-_________ ext ______ Fax #: (_______) _______-_________ ext ______

Email Address: _____________________________ Spouses Name: __________________________________

Children (Names and Ages): _________________________________________________________________________

Emergency Contact

Last:_____________________ First:__________________________Middle:_______________________________

Relationship: ÿ Spouse ÿ Relative ÿ Friend ÿ Other ______________________

Home Phone: (_______) _______-_________ ext ______ Cell Phone: (_______) _______-_________ ext ___

Work Phone: (_______) _______-_________ ext ______

Employment Information

Business Name: ____________________________________________________________________________________

Phone: (_______) _________-____________ Fax #: (_______) _________-____________

Employer’s Email Address: ___________________________

Occupation/Job Title: __________________________ Job Description ______________________________________

Current Health Condition

Unwanted Condition (Why you are here today?):________________

Use the letters BELOW to indicate the TYPE

and LOCATION of your sensations right now.

____________________________________________________________

PLEASE LABEL ON THE DIAGRAM THE AREA OF DISCOMFORT Key: A=Ache B=Burning N = Numbness

® ® ® ® ® ® ® P=Pins & Needles S=Stabbing

When did this Condition BEGIN? _____/_______/_________

Has it ever occurred before? ÿ Yes ÿ No. When? ____________

Is the Condition: ÿ Auto Related ÿ Job Related ÿ Home Injury

ÿ Slip or Fall ÿ Lifting ÿ Slept Wrong ÿ Unknown Cause ÿ Other

Explain: ______________________________________________

______________________________________________________

Date of Accident: _________ Time of Accident: ________ am /pm

Condition/Pain STARTED on what Date: _____________________

Do you SUFFER with ANY OTHER Condition than which you

are now consulting us?

______________________________________________________

REVIEW OF SYSTEMS -Below is a list of symptoms that may seem unrelated to the purpose of your appointment.

However, these questions must be answered carefully as the problems can affect your overall course of care.

Constitutional: ÿ I DENY having or have had any of the symptoms or problems listed below.

ÿ chills	ÿ fatigue	ÿ night sweats	ÿ weight loss
ÿ daytime drowsiness	ÿ fever	ÿ weight gain

Eyes/Vision: ÿ I DENY having any of the symptoms or problems listed below.

ÿ blindness

ÿ change in vision

ÿ field cuts

ÿ photophobia

ÿ blurred vision

ÿ double vision

ÿ glaucoma

ÿ tearing

ÿ cataracts

ÿ eye pain

ÿ itching

ÿ wear glasses/contacts

Ears, Nose and Throat: ÿ I DENY having any of the symptoms or problems listed below.

ÿ bleeding	ÿ ear drainage	ÿ hearing loss	ÿ nosebleeds	ÿ sore throat
ÿ dentures	ÿ ear pain	ÿ history of head injury	ÿ postnasal drip	ÿ tinnitus (ringing in ears)
ÿ difficulty swallowing	ÿ fainting	ÿ hoarseness	ÿ rhinorrhea (runny nose)	ÿ TMJ problems
ÿ discharge	ÿ frequent sore throats	ÿ loss of sense of smell	ÿ sinus infections
ÿ dizziness	ÿ headaches	ÿ nasal congestion	ÿ snoring

Respiration: ÿ I DENY having any of the symptoms or problems listed below.

ÿ asthma	ÿ coughing up blood	ÿ sputum production
ÿ cough	ÿ shortness of breath	ÿ wheezing

Cardiovascular: ÿ I DENY having any of the symptoms or problems listed below.

ÿ angina (chest pain or discomfort)	ÿ high blood pressure	ÿ shortness of breath with exertion or exercise
ÿ chest pain	ÿ low blood pressure	ÿ swelling of legs
ÿ claudication (leg pain/ache)	ÿ orthopnea (difficulty breathing lying down)	ÿ ulcers
ÿ heart murmur	ÿ palpitations	ÿ varicose veins
ÿ heart problems	ÿ paroxysmal nocturnal dyspnea (waking at night w/ shortness of breath)

Gastrointestinal: ÿ I DENY having any of the symptoms or problems listed below.

ÿ abdominal pain	ÿ diarrhea	ÿ indigestion	ÿ abnormal stool caliber	ÿ vomiting blood
ÿ belching	ÿ difficulty swallowing	ÿ jaundice	ÿ abnormal stool color
ÿ black - tarry stools	ÿ heartburn	ÿ nausea	ÿ abnormal stool consistency
ÿ constipation	ÿ hemorrhoids	ÿ rectal bleeding	ÿ vomiting

Female: ÿ I DENY having any of the symptoms/problems and/or using any of the items listed below.

ÿ birth control	ÿ cramps	ÿ irregular menstruation	ÿ vaginal bleeding
ÿ breast lumps/pain	ÿ frequent urination	ÿ pregnancy	ÿ vaginal discharge
ÿ burning urination	ÿ hormone therapy	ÿ urine retention

Male: ÿ I DENY having any of the symptoms or problems listed below.

ÿ burning urination	ÿ frequent urination	ÿ prostate problems
ÿ erectile dysfunction	ÿ hesitancy/ dribbling	ÿ urine retention

Endocrine: ÿ I DENY having any of the symptoms or problems listed below.

ÿ cold intolerance	ÿ excessive hunger	ÿ goiter	ÿ unusual hair growth
ÿ diabetes	ÿ excessive thirst	ÿ hair loss	ÿ voice changes
ÿ excessive appetite	ÿ abnormal frequency of urination	ÿ heat intolerance

Skin: ÿ I DENY having any of the symptoms or problems listed below.

ÿ changes in nail texture	ÿ hair loss	ÿ itching	ÿ skin lesions / ulcers
ÿ changes in skin color	ÿ hives	ÿ paresthesias	ÿ varicosities
ÿ hair growth	ÿ history of skin disorders	ÿ rash

Nervous System: ÿ I DENY having any of the symptoms or problems listed below.

ÿ dizziness

ÿ limb weakness

ÿ numbness

ÿ slurred speech

ÿ tremor

ÿ facial weakness

ÿ loss of consciousness

ÿ seizures

ÿ stress

ÿ unsteadiness of gait/

loss of balance

ÿ headache

ÿ loss of memory

ÿ sleep disturbance

ÿ strokes

Psychologic: ÿ I DENY having any of the symptoms or problems listed below.

ÿ anhedonia	ÿ behavioral change	ÿ convulsions	ÿ memory loss
ÿ anxiety	ÿ bi-polar disorder	ÿ depression	ÿ mood change
ÿ loss or change in appetite	ÿ confusion	ÿ insomnia

Allergy: ÿ I DENY having any of the symptoms or problems listed below.

ÿ anaphalaxis	ÿ itching	ÿ chronic nasal congestion	ÿ sneezing
ÿ food intolerance	ÿ acute nasal congestion	ÿ rash

Hematologic: ÿ I DENY having any of the symptoms or problems listed below.

ÿ anemia	ÿ blood clotting	ÿ bruising easily	ÿ lymph node swelling
ÿ bleeding	ÿ blood transfusion	ÿ fatigue

PAST HEALTH HISTORY – Fill out carefully as these problems can affect your overall course of care.

Previous Care for this Same Condition:

ÿ I have not previously seen a doctor for this condition OR Fill in the information BELOW

Have you seen other doctors for THIS CONDITION? ÿ Yes ÿ No. If yes, Who? (Name) ______________________

Type of Treatment: ____________________ Was the treatment beneficial in resolving condition? ÿ Yes ÿ No

Explain: _______________________________________________________________________________________

Previous Chiropractic Care: ÿ I have not previously seen a Chiropractor OR Fill in the information BELOW.

Doctor’s Name: ________________________ Location: ______________________ Date of Last Visit: ___________

Current Medication (s): List ANY/ALL medications you are CURRENTLY taking. Be Specific.

Medication	Dosage	For What Condition?	How long have you been taking this?

Childhood Illness (es): LIST all health conditions. CIRCLE all CURRENT conditions.

ÿ ADD	ÿ chicken pox	ÿ headaches	ÿ scoliosis
ÿ atopic dermatitis (eczema)	ÿ crohn’s/colitis	ÿ hepatitis	ÿ seizure disorder
ÿ allergies/hayfever	ÿ depression	ÿ HIV	ÿ sickle cell anemia
ÿ anemia	ÿ diabetes	ÿ measles	ÿ spina bifida
ÿ asthma	ÿ ear infections	ÿ mumps	ÿ other:
ÿ bedwetting	ÿ fetal drug exposure	ÿ psoriasis
ÿ cerebral palsy	ÿ food allergies (list below)	ÿ rash

Adult Illness(es): LIST all health conditions. CIRCLE all CURRENT conditions.

ÿ ADD	ÿ cystic kidney disease	ÿ hypertension	ÿ psychiatric problems
ÿ alzheimers	ÿ depression	ÿ influenzal pneumonia	ÿ scoliosis
ÿ anemia	ÿ diabetes (insulin dep)	ÿ liver disease	ÿ seizures
ÿ arthritis	ÿ diabetes (non insulin)	ÿ lung disease	ÿ shingles
ÿ asthma	ÿ eczema	ÿ lupus erythema (discoid)	ÿ past history of similar symptoms
ÿ cancer	ÿ emphysema	ÿ lupus erythema (systemic)	ÿ STD’s (unspecified)
ÿ cerebral palsy	ÿ eye problems	ÿ multiple sclerosis	ÿ suicide attempt(s)
ÿ chicken pox	ÿ fibromyalgia	ÿ parkinson’s disease	ÿ thyroid problems
ÿ crohn’s/colitis	ÿ heart disease	ÿ unspecified pleural effusion	ÿ vertigo
ÿ CRPS (RSD)	ÿ hepatitis	ÿ pneumonia	ÿ other:
ÿ CVA (stroke)	ÿ HIV	ÿ psoriasis

Doctor: Are Child/Adult Illnesses listed contributory to the CURRENT Condition? ÿ yes or ÿ no.

Surgery (ies): LIST All Surgical Procedures. Write the DATE of the Procedure immediately afterward.

ÿ angioplasty	ÿ cosmetic	ÿ hysterectomy	ÿ pacemaker insertion
ÿ appendectomy	ÿ D & C	ÿ joint reconstruction	ÿ rotator cuff
ÿ caesarian section	ÿ dental surgery	ÿ joint replacement	ÿ spinal fusion
ÿ cardiac catheterization	ÿ gall bladder	ÿ knee repair	ÿ tonsilectomy
ÿ carpal tunnel repair	ÿ hemorrhoidectomy	ÿ laminectomy	ÿ other:
ÿ coronary artery bypass	ÿ hernia repair	ÿ mastectomy

Injury (ies): Mark or List All Injuries. Write the DATE of the Injury immediately afterward.

ÿ back injury	ÿ head injury (loss of consciousness)	ÿ motor vehicle accident
ÿ broken bones	ÿ head injury (no loss of consciousness)	ÿ soft tissue injury (mild)
ÿ disability (ies)	ÿ industrial accident	ÿ soft tissue injury (moderate)
ÿ fall (severe)	ÿ joint injury	ÿ soft tissue injury (severe)
ÿ fracture	ÿ laceration (severe)	ÿ other:

Family History: Mark all that apply below. List any specific conditions past or present after has/had:

general family	ÿ alive	ÿ deceased	ÿ normally developed	ÿ no significant disease	ÿ has/had:______________________
father	ÿ alive	ÿ deceased	ÿ normally developed	ÿ no significant disease	ÿ has/had:______________________
mother	ÿ alive	ÿ deceased	ÿ normally developed	ÿ no significant disease	ÿ has/had:______________________
paternal grandfather	ÿ alive	ÿ deceased	ÿ normally developed	ÿ no significant disease	ÿ has/had:______________________
paternal grandmother	ÿ alive	ÿ deceased	ÿ normally developed	ÿ no significant disease	ÿ has/had:______________________
maternal grandfather	ÿ alive	ÿ deceased	ÿ normally developed	ÿ no significant disease	ÿ has/had:______________________
maternal grandmother	ÿ alive	ÿ deceased	ÿ normally developed	ÿ no significant disease	ÿ has/had:______________________
son (s)	ÿ alive	ÿ deceased	ÿ normally developed	ÿ no significant disease	ÿ has/had:______________________
daughter(s)	ÿ alive	ÿ deceased	ÿ normally developed	ÿ no significant disease	ÿ has/had: _____________________
brother(s)	ÿ alive	ÿ deceased	ÿ normally developed	ÿ no significant disease	ÿ has/had: _____________________
sister(s)	ÿ alive	ÿ deceased	ÿ normally developed	ÿ no significant disease	ÿ has/had:______________________

Insurance Information:

Who Is Responsible For Your Bill? YOU and… (mark appropriate box(es)) ÿ Myself ONLY

ÿ Spouse ÿ Worker’s Comp ÿ Auto Insurance ÿ Medicare ÿ Medicaid ÿ Other (be specific):_______________

Personal Health Insurance Carrier: __________________ Health ID Card #: ____________________________

Policy Holder’s Name: _____________________________ Group #: ____________________________________

Policy Holder’s Date of Birth: ______-_____-_______ Primary Care Physician: _______________________

Workers Compensation Injury / Auto / Personal Injury:

Have you filed an injury report with your employer? ÿYes ÿ No Date://Time: _____am/pm

Carrier: _____________________________________________ Policy # _______________________________

Carriers Phone #: (_______) ___________-_______________ Adjuster: ______________________________

Claim #: _____________________________________________

I acknowledge that I have received the Clinic’s Notice of Privacy Practices for protected health information.

Patient Print Name: ______________________________ Date:

Patient’s Signature: ______________________________ Date:

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