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EMSculpt NEO
Emsella
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Services
Chiropractic
Pediatric Chiropractic Care
EMSculpt NEO
Emsella
About
Dr. Peter Riddle
What is Chiropractic?
Our Team
What to Expect
Patient Stories
Contact Us
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Personal Health Information Disclosure Record
First & Last Name
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Relationship To Emergency Contact
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Subscriber/Member's Date of Birth
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Do you have secondary insurance?
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Secondary Insurance Company
Subscriber/Member Name
Subscriber/Member's Date of Birth
Contract/ID Number
Group Number
Accident Information
Is this condition due to an accident?
Yes
No
Type of Accident
Auto
Work
Home
Other
To whom have you made a report of your accident?
Auto Insurance
Employer
Worker's Comp
Other
Date of Accident
Insurance Company (If Applicable)
Attorney Name (If Applicable)
Patient Condition
Reason for Visit
*
When did your symptoms appear?
Is this condition getting progressively worse?
Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain).
Type of Pain
Sharp
Dull
Throbbing
Numbness
Aching
Shooting
Burning
Tingling
Cramps
Stiffness
Swelling
Other
How often do you have this pain?
Constant
Comes & Goes
Does it interfere with:
Work
Sleep
Daily Routine
Recreation
N/A
Health History
What treatment have you already received for your condition?
Medication
Surgery
Physical Therapy
Chiropractic Services
None
Other
What other treatment have you received?
Name and location of other Physician(s) that have treated you for your condition
What other treatment have you received?
What other treatment have you received?
Are you pregnant?
Yes
No
When is your due date?
Place a check mark on "Yes" or "No" to indicate if you have had any of the following:
AIDS/HIV
Yes
No
Alcoholism
Yes
No
Allergy Shots
Yes
No
Anemia
Yes
No
Anorexia
Yes
No
Appendicitis
Yes
No
Arthritis
Yes
No
Asthma
Yes
No
Bleeding Disorders
Yes
No
Breast Lump
Yes
No
Bronchitis
Yes
No
Bulimia
Yes
No
Cancer
Yes
No
Cataracts
Yes
No
Chemical Dependency
Yes
No
Chicken Pox
Yes
No
Diabetes
Yes
No
Emphysema
Yes
No
Epilepsy
Yes
No
Fractures
Yes
No
Glaucoma
Yes
No
Goiter
Yes
No
Gonorrhea
Yes
No
Gout
Yes
No
Heart Disease
Yes
No
Hepatitis
Yes
No
Hernia
Yes
No
Herniated Disc
Yes
No
Herpes
Yes
No
High Cholesterol
Yes
No
Hypertension
Yes
No
Kidney Disease
Yes
No
Liver Disease
Yes
No
Measles
Yes
No
Migraine Headaches
Yes
No
Miscarriage
Yes
No
Mononucleosis
Yes
No
Multiple Sclerosis
Yes
No
Mumps
Yes
No
Osteoporosis
Yes
No
Pacemaker
Yes
No
Parkinson's Disease
Yes
No
Pinched Nerve
Yes
No
Pneumonia
Yes
No
Polio
Yes
No
Prostate Problem
Yes
No
Prosthesis
Yes
No
Psychiatric Care
Yes
No
Rheumatoid Arthritis
Yes
No
Rheumatic Fever
Yes
No
Scarlet Fever
Yes
No
Stroke
Yes
No
Suicide Attempt
Yes
No
Thyroid Problems
Yes
No
Tonsillitis
Yes
No
Tuberculosis
Yes
No
Tumors, Growths
Yes
No
Ulcers
Yes
No
Vaginal Infections
Yes
No
Venereal Disease
Yes
No
Whooping Cough
Yes
No
Other:
Yes
No
What other health condition would you like for us to be aware of?
Describe your exercise habits
None
Moderate
Daily
Heavy
Describe your work activity
Sitting
Standing
Light Labor
Heavy Labor
Habits
Not Applicable
Smoking
Alcohol
Coffee/Caffeine Drinks
High-level Stress
How many packs per day do you smoke?
How many alcoholic drinks per week?
How many cups of coffee/caffeine drinks per day?
What is the reason for your high level of stress?
Have you experienced injuries that could be described as one or more of the following?
Falls
Head Injuries
Broken Bones
Dislocations
Surgeries
Please describe the extent of your fall(s)
Please describe the extent of your head injury(s)
Please describe the extent of your broken bone(s)
Please describe the extent of your dislocation(s)
Please describe the extent of your surgery(s)
Describe any medications you are on
Describe any allergies that you have
Describe any vitamins, minerals and/or herbs you are taking
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