New Patient Center — In Motion Chiropractic

PATIENT INFORMATION

Email

Martial Status

Number of Children

Who is responsible for your bill?

EMPLOYMENT INFORMATION

Employer

Occupation

EMERGENCY CONTACT

Name

Relationship

CURRENT HEALTH CONDITION

Chief Complaint

When did the condition begin?

What have you tried to make it feel better?

What makes the pain worse?

Does the pain travel up or down in your body?

Rate your pain

Is your pain worse in the morning, noon or night?

MEDICATION, HERBS, SUPPLEMENTS

Name

Why do you take this Medications, Herbs or Supplement?

Name

Why do you take this Medications, Herbs or Supplement?

Name

Why do you take this Medications, Herbs or Supplement?

Any other Medications, Herbs or Supplements?

LIFESTYLE

Height

Weight

Age

Allergies

Describe your diet

Types of exercise

Hours per week

What are you training for?

Alcohol per week

Average sleep time

Current stress level

PAST HEALTH HISTORY

Please report any past health conditions that may affect a proper diagnosis.

If yes, please explain

Name of Doctor

Review of Systems

(check all that apply)

When was your last period?

Consent for Treatment and Insurance Authorization

I hereby authorize the release of information to my insurance company concerning the charges and treatment provided to me by the doctor of Chiropractic at In Motion Sports and Family Chiropractic. I hereby assign benefits and I Understand that payment is due as services are provided, including my deductible, co-payment, coinsurance, or any balance not paid by my insurance company(excluding contractual allowance).if, after 60 days, insurance payment has not been received. I understand that the charges are my responsibility and payable immediately. Additionally, I consent to treatment as deemed necessary by the Doctor of Chiropractic at In Motion Sports and Family Chiropractic

to make an Appointment AND CREATE A NEW PATIENT PROFILE CLICK ON “Scheduling” (above on the menu bar).