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Patient/Accident Information Form ----------

About You Female .. Male Name: Nickname: Street Address: City: State: Zip: Home Phone: Work Phone: Date of Birth: Social Security #: - - Employer:: Occupation:: Marital Status: Single Married Separated Divorced Spouse Name: Spouse Social Security #: - - Spouse Employer: Spouse Date of Birth: Name and age of children: Name of nearest relative not living with you: (If under 18) Name of parent our guardian: Parent or Guardian home phone Parent or Guardian work phone

Chief Complaint Please describe your injuries and symptoms. (How do you feel? Where does it hurt) Symptom: Check the symptoms you have noticed: Memory Loss Pain moving into Legs Pain in Jaw Headache Head seems to Heavy Clicking/Popping in Jaw Neck Pain Pins and Needles in Arm Dizziness Neck Stiffness Pins and Needles in Legs Loss of Balance Upper Back Pain Numbness in Fingers Nausea Middle Back Pain Numbness in Toes Constipation Lower Back Pain Tingle in Fingers Diarrhea Nervousness Tingle in Toes Cold Feet Bruises Shortness of Breath Cold Hands Cuts Fatigue (Tired). Upset Stomach Nightmares Depression Cold Sweats Irritability Tension Light Bothers Eyes Fever Chest Pains Flushed Faces Blood in Urine Pain moving into Arms Broken Bones Nose Bleeds Sleeping Problems Allergies Vomiting       Symptoms NOT listed above: Date condition began or date of accident: Time: AM PM What makes you feel better: What makes you feel worse: Describe your accident: Have you missed work because of your accident? Yes No HAre your WORK activities restricted? Yes No If yes, explain. Are your RECREATION activities restricted? Yes No If yes, explain.

Past Medical History Have you seen another doctor for this condition: If yes, who?   Previous Doctor of Chiropractic care? If yes who?   When was your last visit? Who is your family physician?   When was your last visit? What non-prescription drugs are you taking? What prescription drugs are you taking? What side effects do these drugs have?  Have you had any of the following diseases? Anemia Heart Disease Arthritis Epilepsy Mental Disorder Liver Disease Polio Tuberculosis Diabetes Cancer AIDS/HIV Kidney Disease Other: Have you ever been hospitalized? Yes No If yes, explain. Have you ever broken any bones? Yes No If yes, explain. Do you have any congenital and or birth conditions? Yes No If yes, explain.

Family Health History   Back Pain Heart Problems Stroke Cancer Diabetes High Blood Pressure Mother: Father: Sisters: Brothers: Other:

Insurance Information No Insurance .............. Medicare.............. Major Medical Personal Injury (auto accident or fall).......... Worker's Compensation Your insurance Company:

Patient Signature:_______________________________ Date:_________________