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Mountain Home Family Chiropractic | 640 Hwy 62 E | Mountain Home, AR 72653 | Phone: 870-425-4424 | Fax: 870-425-7848 | page 1
Rev 6/27/2012
In order to provide you the best possible care, please complete this form and bring it to your first appointment. All information is kept strictly CONFIDENTIAL. If you have any questions, please call our office at 870-425-4424.
Date
Doctor Case #
Full Name
Referred by
Contact Information
Street Address
City/State/Zip
Home Phone (
)
Cell Phone (
)
Best way to reach me Home Phone Cell Phone Work Phone Email Mail
Please sign me up for membership to the Mountain Home
Family Chiropractic website and health emails. I can opt-out at any time. I would like to receive information regarding:
Headaches and Neck Pain Backaches and Sciatica Children’s Health Women’s Health
General Wellness Diet and Nutrition Exercise and Fitness Stress Management
Personal Information
Male Female Single Married Other
Date of Birth
Age
Social Security #
Driver’s License #
Work/School Information
Employed: Full Time Part Time
Employer Name
Occupation
Street Address
City/State/Zip
Work Phone (
)
Student: Full Time Part Time
School Name
Course of Study
Spouse/Significant Other Information
Name
Date of Birth
Employer Name
Occupation
Employer Address
City/State/Zip
Work Phone (
)
Home Phone (
)
Cell Phone (
)
Social Security #
Mountain Home Family Chiropractic | 640 Hwy 62 E | Mountain Home, AR 72653 | Phone: 870-425-4424 | Fax: 870-425-7848 | page 2
Rev 6/27/2012
CURRENT HEALTH CONDITIONS & HEALTH HISTORY
Have you ever suffered from: Alcoholism
Allergies
Anemia
Arteriosclerosis
Arthritis
Asthma
Back Pain
Breast Lump
Bronchitis
Bruise Easily
Cancer
Chest Pain/Conditions
Cold Extremities
Constipation
Cramps
Depression
Diabetes
Digestion Problems
Dizziness
Ears Ringing
Excessive Menstruation
Eye Pain or Difficulties
Fatigue
Frequent Urination
Headaches
Hemorrhoids
High Blood Pressure
Hot Flashes
Irregular Heart Beat
Irregular Cycle
Kidney Infection
Kidney Stones
Loss of Memory
Loss of Balance
Loss of Smell
Loss of Taste
Lumps In Breast
Neck Pain or Stiffness
Nervousness
Nosebleeds
Pacemaker
Polio
Poor Posture
Prostate Trouble
Sciatica
Shortness of Breath
Sinus Infection
Sleep Problems or Insomnia
Spinal Curvatures
Stroke
Swelling of Ankles
Swollen Joints
Thyroid Condition
Tuberculosis
Ulcers
Varicose Veins
Venereal Disease
Other:
.
..
..
..
Please use the following letters to indicate TYPE and LOCATION of the symptoms you currently are experiencing.
A=Ache O=Other B=Burning P=Pins & Needles N=Numbness S=Stabbing
Mountain Home Family Chiropractic | 640 Hwy 62 E | Mountain Home, AR 72653 | Phone: 870-425-4424 | Fax: 870-425-7848 | page 3
Rev 6/27/2012
Have you received Chiropractic Care before? No Yes If yes, when?
Chief Complaint(s)
Complaint began (date)
Duration of complaint
Nature of injury Automobile Work Other
Have you had this before? No Yes Explain
Did you hurt yourself? No Yes Explain
Is condition getting worse? No Yes Condition interferes with
How frequent is it and how long does it last?
Are symptoms worse at certain times of day? Explain
Do weather changes affect your symptoms? Explain
Quality of the pain dull aching sharp shooting burning throbbing deep nagging
Other:
Does pain radiate or travel to any areas of your body? Yes No Explain
Do you have any numbness or tingling in your body? Yes No Explain
Rate the Pain Intensity/Severity (0 = No pain) 0 1 2 3 4 5 6 7 8 9 10 (10 = Worst possible pain)
Does anything aggravate the complaint? No Yes Explain
Does anything make the complaint better? No Yes Explain
Previous doctors, treatments, medications, or surgery you’ve sought for your complaint
Secondary Complaint(s)
Have you been treated for any conditions in the last year? No Yes Explain
Current health conditions (other than chief complaint)
Date of last physical exam
Given by
Mountain Home Family Chiropractic | 640 Hwy 62 E | Mountain Home, AR 72653 | Phone: 870-425-4424 | Fax: 870-425-7848 | page 4
Rev 6/27/2012
Are you pregnant? Yes No
Have you ever had x-rays taken? No Yes Where and why
Have you ever had broken bones? No Yes Explain
Have you ever been hospitalized? No Yes Explain
Have you ever been in an auto accident? No Yes Explain
Have you ever had sprains/strains? No Yes Explain
Have you ever been struck unconscious? No Yes Explain
Have you ever had surgery? No Yes Explain & dates
Allergies
Current medications (please list condition, dosage, and frequency)
Current vitamins, minerals, and herbs (please list dosage and frequency)
PATIENT AGREEMENT / ASSIGNMENT & RELEASE
1. I hereby consent to allow Mountain Home Family Chiropractic to treat me for my condition. 2. I have received the notice of Privacy Policies and have had the opportunity to review it. 3. I hereby authorize Mountain Home Family Chiropractic to release any information deemed appropriate concerning
my physical condition to any insurance company, attorney, or adjuster in order to process any claim for reimbursement of charges incurred. I further give my permission to use and disclose my health information to others for the purpose of treatment, obtaining payment, or supporting the day-to-day healthcare operations of this office.
4. I hereby authorize the direct payment to Mountain Home Family Chiropractic of any sum I now or hereafter owe by my attorney out of any proceeds of any settlement of my case, and by any insurance company obligated to make payment to me or Mountain Home Family Chiropractic based in whole or in part upon the charges made for services.
5. I am aware that Mountain Home Family Chiropractic regards my insurance policy as an agreement between me and my insurance company, and as such, Mountain Home Family Chiropractic is not a party of that contract. Therefore, in the event that my insurance has not paid within 60 days, I will be billed for the balance.
6. If I am a CASH patient, I understand that the balance is due at the time of service. If I begin a CASH PAYMENT PLAN (2 yr, 1 yr, or 6 months), Mountain Home Family Chiropractic will only accept a voided check or credit/debit card number for payment.
7. I hereby authorize the use of this signature on all my insurance submissions. 8. I agree to all the above terms and conditions.
Patient Signature Date Signed
Relationship to Patient (if patient is a minor)