PATIENT NAME

Last Name: _____________________________________ First Name:_________________________ MI: __________

Gender: M F Date of Birth _______/_______/_______ Age: __________ SS#:________________________

Home Address: ________________________________________________________ Apt #: ____________________

City: ______________________________________ State/Zip: ____________________________________________

E-mail Address: _________________________________ Who referred you to our office? _______________________

Home Phone#: _________________________________ Work Phone #: _____________________________________

Employer Name: ________________________________ Occupation: ______________________________________

Employer Address: ____________________________________ City: ___________________ State/Zip: ___________

SPOUSE OR GUARDIAN

Last Name: _____________________________________ First Name:_________________________ MI: ___________

Employer Name: ________________________________ Work Phone #: ____________________________________

Date of Birth _______/_______/_______ SS#:__________________________________________________________

EMERGENCY (Name and address of nearest relative or friend not living with you)

Last Name: _____________________________________ First Name:_______________________________________

Home Phone #: __________________________________ Work Phone #: ____________________________________

Relationship to Patient: _____________________________________________________________________________

What are your presenting complaints? _________________________________________________________________

_________________________________________________________________________________________________

MY CERTIFICATION

I certify that the above information is correct and I request services.

x_____________________________________________________________________ Date: ______________________Signature of patient or person acting on patient’s behalf.

MY PRIVACYI have received a copy of the Notice of Privacy Practices. I understand that I have certain rights to privacy regarding the protection of my health information. I understand that this information can be used to: Conduct, plan & direct mytreatment and follow-up among the healthcare providers who may be directly and indirectly involved in providing mytreatment; Obtain payment from third-party payors; Conduct normal healthcare operations, such as quality assessmentand accreditation.

x_____________________________________________________________________ Date: ______________________

PATIENT INFORMATION

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PATIENT NAME

Last Name: _____________________________________ First Name:_________________________ MI: __________

INSURANCE TYPESELF INSURANCE ( ) MEDICARE ( ) AUTO ( ) WORKERS COMPENSATION ( )

INSURANCE (We require a copy of your card (s) for our records)

Insurance Company: __________________________________________ Phone #: ____________________________

Insured’s Name: ______________________________________________ ID/Policy #: __________________________

Insurance Company: __________________________________________ Phone #: ____________________________

Insured’s Name: ______________________________________________ ID/Policy #: __________________________

AUTO INSURANCE (Please note: In Idaho, we are required to bill your auto insurance if you have a personal injuryprotection on your policy, even if the third person is at fault).

Insurance Company: __________________________________________ Phone #: ____________________________

Insurance Company Address: ___________________________________ Policy #: ____________________________

Claim #: ___________________________________________ Date of Accident: _______________________________

RESPONSIBLE PARTY (Complete this section if you are not the patient but are responsible for the bill)

Responsible Party Name: ____________________________________ Relationship to Patient: __________________

Home Address: ________________________________________________________ Apt #: ____________________

City: ______________________________________ State/Zip: ____________________________________________

Home Phone#: _________________________________ Work Phone #: _____________________________________

Employer Name: ________________________________ Occupation: ______________________________________

MY FINANCIAL RESPONSIBILITYI certify that the above information is correct. I understand that I am personally financially responsible for allservices. I am also responsible for any annual deductibles applicable, co-payments, or non-covered servicesas may be required by my insurance plan.

x_____________________________________________________________________ Date: ______________________Signature of patient or person acting on patient’s behalf.

MY AUTHORIZATIONI authorize the release of any medical records or other information to process my claims. I also request payment of government or private benefits, either to myself or to the party who accepts assignment. This is a permanent authorization that I may revoke at any time by written notice.

x_____________________________________________________________________ Date: ______________________Signature of patient or person acting on patient’s behalf.

INSURANCE INFORMATION

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Please check the degree of all conditions you currently have or have had. To be responsible for your case, we need your complete health history. O= Occasional F=Frequent C=Current O F C MUSCLE / JOINT Arthritis

Bursitis

Foot Trouble Hernia Low Back Pain

Neck Pain, Stiffness

Pain Between Shoulders

GENERAL Allergies

Chills

Convulsions

Dizziness

Fainting

Headaches

Loss of Sleep

Loss of Weight

Nervousness, Depression Neuralgia Numbness

Sweats

TremorsCARDIOVASCULAR Hardening of Arteries High Blood Pressure Low Blood Pressure

Pain Over Heart

Poor Circulation

Rapid Heartbeat

Slow Heartbeat

Swelling of AnklesGENITOURINARY Bed-wetting Blood in Urine

Lack of Bladder Control

Painful Urination

Prostate Trouble

Please list any other conditions youhave not listed above______________________________________________________________________________

Please list the drugs you now take:________________________________________________________________

SYSTEMS REVIEW

O F C EYE, EAR, NOSE & THROAT Asthma

Colds

Crossed Eyes Deafness Dental Decay

Earache

Ear Noise Enlarged Glands

Enlarged Thyroid

Eye Pain

Failing Vision

Far Sightedness

Gum Trouble

Hay Fever

Hoarseness

Nasal Obstruction

Near Sightedness

Nose Bleeds

Sinus Infection

Sore Throat

Tonsilitis

GASTROINTESTINAL Belching or Gas Colitis Colon Trouble

Constipation

Diarrhea

Difficult Digestion

Bloated Abdomen

Excessive Hunger

Gallbladder Trouble

Hemorrhoids

Intestinal Worms

Jaundice

Liver Trouble

Nausea

Pain Over Stomach

Poor Appetite

Vomiting

Vomiting of Blood

O F C SKIN Boils

Bruises Easily

Dryness Hives or Allergies Itching

Skin Rash

Varicose Veins

PAIN OR NUMBNESS

Shoulders

Arms

Hands

Hips

Legs

Knees

Feet

Painful Tailbone

Poor Posture

Sciatica

Spinal Curvature

Swollen JointsRESPIRATORY Chest Pain Chronic Cough Difficulty Breathing

Spitting Up Blood

Spitting Up Phlegm

WheezingWOMEN ONLY

Congested Breast

Cramps or Backache

Excessive Mentrual Flow

Hot Flashes

Irregular Cycle

Lumps in Breast

Menopause

Painful Menstruation

Vaginal Discharge

ARE YOU PREGNANT Y or N

If yes, how many months? ________

How many children do you have? _______

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PLEASE CIRCLE “YES” or “NO” TO THE FOLLOWING QUESTIONSDo you think you need minerals, herbs or vitamins? Yes NoDo you have any drug allergies? If yes, what is it to? Yes No _______________________________Have you had a spinal X-ray? If yes, when? Yes No _______________________________________Have you had a spinal examination? If yes, when? Yes No __________________________________Have you had a physical examination? If yes, when? Yes No ________________________________

PLEASE LIST ANY OTHER HEALTH CONDITIONS THAT YOU HAVE HAD IN THE LAST 5 YEARS__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

INFORMED CONSENT TO CHIROPRACTIC ADJUSTMENTS AND CARE

I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic x-rays, on me (or the patient named below, for whom I am legallyresponsible) by the doctor of chiropractic named below and/or other licensed doctors of chiropractic who nowor in the future treat me while employed by, working or associated with, or serving as back-up for the doctor ofchiropractic named below, including these working at the clinic or office listed below or any other office or clinic.

I have had the opportunity to discuss with the doctor of chiropractic named below and /or with other office or clinicpersonnel the nature and purpose of chiropractic adjustments and other procedures. I understand that the results are notguaranteed.

I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment,including, but not limited to, fractures, disc injuries, strokes, dislocations, and sprains. I don not expect the doctor to be ableto anticipate and explain all risks and complications, and wish to rely on the doctor to exercise judgment during the courseof the procedure, which the doctor feels at the time, based upon the facts known, is in my best interest.

I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, andby signing below, I agree to the above-named procedures. I intend this consent form to cover the entire course of treatmentfor my present conditions and for any future conditions for which I may seek treatment.

To Be Completed by Patient To Be Completed by patient’s representative

_____________________________________________________ _________________________________________________Print Patients Name Print Patients Name

_____________________________________________________ _________________________________________________Signature of Patient Print Name of Patient’s Representative

_____________________________________________________ _________________________________________________Date Signed Signature of Patient’s Representative _________________________________________________Ironwood Chiropractic Center / Dr. Bradley S. Reed Date Signed2201 N. Government Way, Suite D Coeur d’Alene, ID 83814Tel: 208-667-0823 Fax: 208-664-5251 Page 4