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Personal Health Information Disclosure Record First & Last Name * Email Address * Date of Birth * Today's Date Street Address * City State ZIP Residence Telephone Work Telephone Cell Phone * SexMaleFemale Age Marital Status MarriedWidowedSingleMinorSeparatedDivorcedPartnered Authorized Methods of Communication - Select all that apply Residence TelephoneWork TelephoneCell TelephoneWritten Correspondence Leave call back number only; do not leave a messageOkay to leave detailed message with personOkay to leave detailed message on personal voicemail Leave call back number only; do not leave a messageOkay to leave detailed message with personOkay to leave detailed message on personal voicemail Leave call back number only; do not leave a messageOkay to leave detailed message with personOkay to leave detailed message on personal voicemail Secondary Email Address Fax Relationship to Patient: SelfParentLegal GuardianPersonal Representative Emergency Contact Emergency Contact Name * Relationship To Emergency Contact * Home Phone Work Phone Cell Phone Employment Information Patient's Occupation * Patient's Employer/School Patient's Employer's Address Spouse's Name Spouse's Date of Birth Spouse's Employer Spouse's Employer's Phone Primary Insurance Company * Subscriber/Member Name * Subscriber/Member's Date of Birth * Contract/ID Number Group Number Do you have secondary insurance?YesNo 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? YesNo Type of Accident AutoWorkHomeOther To whom have you made a report of your accident? Auto InsuranceEmployerWorker's CompOther 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 SharpDullThrobbingNumbnessAchingShootingBurningTinglingCrampsStiffnessSwellingOther How often do you have this pain? ConstantComes & Goes Does it interfere with: WorkSleepDaily RoutineRecreationN/A Health History What treatment have you already received for your condition? MedicationSurgeryPhysical TherapyChiropractic ServicesNoneOther 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? YesNo 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 YesNo Alcoholism YesNo Allergy Shots YesNo Anemia YesNo Anorexia YesNo Appendicitis YesNo Arthritis YesNo Asthma YesNo Bleeding Disorders YesNo Breast Lump YesNo Bronchitis YesNo Bulimia YesNo Cancer YesNo Cataracts YesNo Chemical Dependency YesNo Chicken Pox YesNo Diabetes YesNo Emphysema YesNo Epilepsy YesNo Fractures YesNo Glaucoma YesNo Goiter YesNo Gonorrhea YesNo Gout YesNo Heart Disease YesNo Hepatitis YesNo Hernia YesNo Herniated Disc YesNo Herpes YesNo High Cholesterol YesNo Hypertension YesNo Kidney Disease YesNo Liver Disease YesNo Measles YesNo Migraine Headaches YesNo Miscarriage YesNo Mononucleosis YesNo Multiple Sclerosis YesNo Mumps YesNo Osteoporosis YesNo Pacemaker YesNo Parkinson's Disease YesNo Pinched Nerve YesNo Pneumonia YesNo Polio YesNo Prostate Problem YesNo Prosthesis YesNo Psychiatric Care YesNo Rheumatoid Arthritis YesNo Rheumatic Fever YesNo Scarlet Fever YesNo Stroke YesNo Suicide Attempt YesNo Thyroid Problems YesNo Tonsillitis YesNo Tuberculosis YesNo Tumors, Growths YesNo Ulcers YesNo Vaginal Infections YesNo Venereal Disease YesNo Whooping Cough YesNo Other: YesNo What other health condition would you like for us to be aware of? Describe your exercise habits NoneModerateDailyHeavy Describe your work activity SittingStandingLight LaborHeavy Labor Habits Not ApplicableSmokingAlcoholCoffee/Caffeine DrinksHigh-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? FallsHead InjuriesBroken BonesDislocationsSurgeries 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 By signing this document, you are confirming that you agree with Discover Chiropractic's terms and conditions. * Yes, I agree with terms and conditions. Signature Start signing your signature here Your browser does not support e-Signature field. Send Message
