Patient History Forms | Align the Spine Chiropractic

PATIENT DEMOGRAPHICS

Today's Date(Required)

Name(Required)

First Last

Birthdate(Required)

Age(Required)

Sex(Required)

Male

Female

Address(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone

Work Phone

Mobile Phone(Required)

Email(Required)

Marital Status(Required)

Single

Married

Do you have insurance?(Required)

Yes

No

Employer(Required)

Occupation(Required)

Spouse’s Name

First Last

Spouse’s Employer

Number of children and age(Required)

Emergency Contact Name(Required)

First Last

Emergency Contact Phone(Required)

Relationship(Required)

HISTORY OF COMPLAINT

Please identify the condition(s) that brought you to this office

Primary(Required)

Secondary

Third

Fourth

On a scale of 0 to 10 with 10 being the worst pain and zero being no pain, rate your above complaints by circling the number:

Primary(Required)

Second

Third

Fourth

When did the problem(s) begin?(Required)

When is the problem at its worst?(Required)

How long does it last?(Required)

How did the injury happen?(Required)

Condition(s) ever been treated by anyone in the past?(Required)

Yes

No

When?(Required)

by whom?(Required)

How long were you under care?(Required)

What were the results?(Required)

Name of previous chiropractor:(Required)

First Last

Please describe the areas on the body that casuses pain(Required)

Choose which describes your symptoms(Required)

What relieves your symptoms?(Required)

What makes your symptoms feel worse?(Required)

LIST RESTRICTED ACTIVITY(Required)

CURRENT ACTIVITY LEVEL(Required)

USUAL ACTIVITY LEVEL(Required)

Is your problem the result of ANY type of accident?(Required)

Identify any other injury(s) to your spine, minor or major, that the doctor should know about:(Required)

PAST HISTORY

Have you suffered with any of this or a similar problem in the past?(Required)

If yes, how many times?

When was the last episode?(Required)

How did the injury happen?(Required)

Other forms of treatment tried?(Required)

If yes, please state what type of treatment

who provided it?(Required)

How long ago?(Required)

What were the results(Required)

Please explain

Please identify any and all types of jobs you have had in the past that have imposed any physical stress on you or your body(Required)

have ever been diagnosed with any of the following conditions

Broken Bone(Required)

Dislocations(Required)

Tumors(Required)

Rheumatoid Arthritis(Required)

Fracture(Required)

Cancer(Required)

Heart Attack(Required)

Disability(Required)

Osteo Arthritis(Required)

Diabetes(Required)

Cerebral Vascular(Required)

Other serious conditions:(Required)

PLEASE IDENTIFY ALL PAST and any CURRENT conditions you feel may be contributing to your present problem:

INJURIES(Required)

CHILDHOOD DISEASES(Required)

SURGERIES(Required)

ADULT DISEASES(Required)

FAMILY HISTORY

Does anyone in your family suffer with the same condition(s)?(Required)

If yes, whom?

grandmother

grandfather

mother

father

sister(s)

brother(s)

son(s)

daughter(s)

Have they ever been treated for their condition?(Required)

Any other hereditary conditions the doctor should be aware of?(Required)

REVIEW OF SYSTEMS

Please choose Past, Currently or Never for each system:

Headache(Required)

Pregnant (Now)(Required)

Dizziness(Required)

Prostate Problems(Required)

Ulcers(Required)

Neck Pain(Required)

Frequent Colds/Flu(Required)

Loss of Balance(Required)

Impotence/Sexual Dysfun.(Required)

Heartburn(Required)

Jaw Pain, TMJ(Required)

Convulsions/Epilepsy(Required)

Digestive Problems(Required)

Heart Problem(Required)

Shoulder Pain(Required)

Tremors(Required)

Double Vision(Required)

Colon Trouble(Required)

High Blood Pressure(Required)

Upper Back Pain(Required)

Chest Pain(Required)

Blurred Vision(Required)

Diarrhea/Constipation(Required)

Low Blood Pressure(Required)

Mid Back Pain(Required)

Pain w/Cough/Sneeze(Required)

Menopausal Problems(Required)

Asthma(Required)

Low Back Pain(Required)

Foot or Knee Problems(Required)

Hearing Loss(Required)

Menstrual Problem(Required)

Difficulty Breathing(Required)

Hip Pain(Required)

Sinus/Drainage Problem(Required)

Depression(Required)

PMS(Required)

Lung Problems(Required)

Back Curvature(Required)

Swollen/Painful Joints(Required)

Irritable(Required)

Bed Wetting(Required)

Kidney Trouble(Required)

Scoliosis(Required)

Skin Problems(Required)

Mood Changes(Required)

Learning Disabilty(Required)

Gall Bladder Trouble(Required)

Numb/Tingling arms, hands, fingers(Required)

ADD/ADHD(Required)

Eating Disorder(Required)

Liver Trouble(Required)

Numb/Tingling legs, feet, toes(Required)

Allergies(Required)

Trouble Sleeping(Required)

Hepatitis (A,B,C)(Required)

Patient or Authorized Person's Name(Required)

First Last

Signature(Required)

Date(Required)

Doctor's Signature & Date Signed

Office Use Only

Quadruple Visual Analogue Scale

Please read carefully: Instructions: Please choose the number that best describes the question being asked Note: If you have more than one complaint, please answer each question for each individual complaint and indicate the score for each complaint. Please indicate your pain level right now, average pain, and pain at it's best and worst.

Example:

What is your pain RIGHT NOW?(Required)

What is your TYPICAL or AVERAGE pain?(Required)

What is your pain level AT ITS BEST (How close to “0” does your pain get at its best)?(Required)

What is your pain level AT ITS WORST (How close to “10” does your pain get at its worst)?(Required)

Other Comments:

Doctor's Signature & Date Signed

Office Use Only

Health Objectives & Clinic Policies

1.) Education - To take control of your health: In order for you to be able to achieve your health goals, our office educates our patients. We also use an online platform, called MoveNow University, to provide a variety of resources and videos that cover health topics and functional exercises to supply the tools you need to achieve those health goals and to transform your life.

2.) Scheduling and appointments: Our most successful patients are the ones who schedule out, and stick with it.

In order for you to reserve times that work best for your schedule, we ask you to schedule out as far in advance as possible (entire 3-4 months is preferred).
It is important to remember, that the times that you schedule are times that we are reserving for you, and turning other patients away.
Should you have to change an appointment time, please call us with as much advanced notice as possible. Cancellations made in less than 24 hours of the scheduled appointment time will result in a cancellation fee of $50.00 per missed appointment, this includes no call no show appointments.
If you MUST cancel an appointment, please be prepared to reschedule at that time of cancellation. We ask that you make up this appointment.
If you may be running late to an appointment, please call our office so we can ensure your appointment is still safe. Please understand if we are still able to accommodate your appointment that their might be some extra waiting or all services might not be rendered.
If you have any concerns about your frequency or care, please let the front office know and we will help resolve any issues.

3.) Our Mission is to help our patients to achieve a better quality of life: Please help us spread the word by inviting your friends, family and co-workers with you to an appointment so they can see what we do. This is the best way to help those you know who are suffering! I consent to receive email/text updates about clinic promotions, patient education and all other clinic communications.

Email(Required)

Signature(Required)

I understand the above policies and know that what I put into my health is what I will receive in return.

Date(Required)

Email/text notification Opt-in(Required)

Yes

No

Financial Policy

Notice:

In an effort to maintain compliance with various state and federal regulations, managed care and preferred provider agreements, as well as billing and coding guidelines, we have adopted the following financial policies:

Our clinic has established a single fee schedule that applies to all patients for each service provided.

You may be entitled to a network or contractual discount under the following circumstances:

▪ Patients who meet state and or federal poverty guidelines or other special circumstances outlined in our “Hardship Policy” may be offered a discount for a period of time as determined by the clinic. Verification will be required.

▪ Patients who meet the terms outlined in our “Professional Courtesy Policy” may be offered a discount for services.

▪ Patients who are a part of an Employee Corporate Program will be eligible for discounts as agreed upon and outlined in writing between both Align the Spine Chiropractic, LLC and the company of the employee. These discounts will be specified to individuals by their place of employment. As part of our compliance plan, as of 12/1/21 our office will be unable to extend any type of discounts other than those listed above.

Acknowledged By: Name(Required)

First Last

Signature(Required)

Date(Required)

Align the Spine

New Patient Forms

PATIENT DEMOGRAPHICS

HISTORY OF COMPLAINT

PAST HISTORY

FAMILY HISTORY

SOCIAL HISTORY

Authorization

ACTIVITIES OF LIFE

REVIEW OF SYSTEMS

Quadruple Visual Analogue Scale

Health Objectives & Clinic Policies

Financial Policy