Please provide the following contact information:
Patient's Name Today's Date
Home Phone Cell Phone # Work Phone
Permanent Address Apt # City
State/Prov Zip/Postal Code/Country E-mail Address NOTE: Legault Chiropractic does NOT sell nor share your e-mail address with Any outside parties, except as You request. We may send you an E-Newsletter once a month &/or a notice of any "Specials of the Month" as they may interest you.
Local Street Address (if different) Local Tel #
City State Zip
Gender . Male Female Marital Status . Single Married Civil Partner Widowed Separated Divorced Date of Birth Occupation RETIRED
Place of Employment Social Security # Name of Spouse
Insurance Company
Name of Children & Age
WHOM may we be Thank for Referring You to our office?
Have you EVER had Chiropractic Care in the Past ? . Yes No If "YES" Please indicate When?
Name of your prior Chiropractor Where? and Why did you stop?
Was it a Great experience? . Yes No Did they take Spinal X-rays? Yes . No I can not recall Approx date of Last Spinal X-rays
HOW CAN WE SERVE YOU?
What is you reason for seeking Chiropractic care
I have no complaints. I am here for a wellness check up.
I am seeking Chiropractic care for the following -
Is this related to: Personal Health Problem(s) Work Accident Auto Accident School/Sports Injury
Other
SUBLUXATIONS (spinal misalignments) interfere with the communication from your brain to your body. When these interferences are advanced, an alarm system occasionally signals for help by sending signs or symptoms such as pain, numbness &/or health problems to let you know that there is a problem. Please let us know where the alarm system is sounding on you?
Neck Pain Headaches Shoulder/Arm/Hand Pain Allergies
Mid Back Pain Dizziness Hip/Leg/foot Pain Sinus Problems
Low Back Pain Nervousness Digestive Problems Loss of Sleep
Constipation Numbness/Tingling Difficulty Breathing Urinary Problems
(Females only: Are You Pregnant? NO YES Do you/Did you have Menstrual Problems NO YES Signs of Menopause NO YES )
When did these signs or symptoms that brought you here 1st appear? Are these signs or symptoms: . Constant Frequent Occasional Intermittent
A Subluxation irritates nerves with various sensations. Is yours? (Select Any /All of the following options that apply):
Sharp Burning Throbbing Stabbing Dull Achy
SOCIAL HABITS: Do you Exercise daily Eat a healthy diet
Water Consumption . 1 or Less 2 3 4 5 6 7 8 9 10 + # of glasses per day Tobacco/Smoke . None Less than 1 1 2 3 4 5 6 + # packs per day
Alcohol Consumption . Never/None Occasionally Socially Daily Drug Consumption . Never/None Occasionally Socially Daily
PAST HISTORY: Have you EVER had any SURGERY: Select any/ALL of the following options that apply:
Tonsils Appendix Gall Bladder Heart Cancer Spinal Surgery
Other I have NEVER had Any Surgeries
(Females Only:Caesarian Hysterectomy Other
Please LIST ALL MEDICATIONS for ANY Health Problem(s)
REVIEW OF BODY SYSTEMS: (Examples Only, Your Problem(s) may be Different) Please “CHECK OFF Any/ALL System which gives you a problem or for which you are taking medications.
HEART/CIRCULATION (Bld. Pressure) LUNGS/RESPIRATORY (Asthma) GASTROINTESTINAL (Heartburn/Constip./Diarrhea)
BLOOD/LYMPHATIC (Leukemia/HIV Pos.) NEUROLOGICAL (Numbness/paralysis) ENDOCRINE/HORMONES (Diabetes/Thyroid/Female Hormones)
EYES (Glasses/Glaucoma/ Other) IMMUNE SYSTEM (Freq. Colds/Fever) SKIN (Rashes/Pimples/Skin Cancer)
EARS/NOSE/THROAT/MOUTH GENITO/URINARY (Reproductive/Bladder) PSYCHIATRIC (Depression / Extreme Stress)
RESPONSIBILITY:
PERSON/ENTITY RESPONSIBLE FOR THIS ACCOUNT: SELF SELF + SPOUSE / GUARDIAN SELF + INSURANCE
NOTE: It is the Patient's Responsibility to Notify the Legault Chiropractic Health Center Who is Liable for Charges incurred &/or to be incurred in this Office & Re-Notify Immediately if their "Care Liability" CHANGES while under care. [ex. from-to: Personal / Auto Accident / Workers' Comp / Other]
PRIVACY STATEMENT: We, at the Legault Chiropractic Health Center , honor and respect all of our patients & their right to privacy. It is the regular policy of this office to minimize disclosure or dissemination of any personal information on any/all of our patients. Neither your name, address, phone number(s) nor health/financial record will be used, nor shared with any outside agent, except as expressed & authorized by you (example – your spouse &/or Insurance Company) or as Required by Law.
FEES ARE DUE WHEN SERVICES ARE RENDERED, UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE.
[A copy of your driver’s license is mandatory if payments are to be Other than CASH.]
I hereby authorize the Legault Chiropractic Health Center to disclose my private health and financial information to &/or (ex: Name your Spouse/Parent/Adult-Child /Insurance Company) for the purpose of payment, coordination of my care &/or to transport said information for me in my absence.
Signature of Patient Date mm/dd/yy
Patient's Authorization for Care
By signing below I authorize the Legault Chiropractic Center to evaluate and treat me, my minor, or my legal dependant.
I consent to be evaluated and receive chiropractic care SIGNATURE: Date mm/dd/yy
I understand that if I Sign &/or Send this Form Electronically, that my Electronic Signature is the SAME as a Hand Written Signature. [Electronic Transmission NOT Available at this time.]
To PRINT Click 'CTRL' + 'P' at same time
Please NOTE: At this time, this form can NOT be Transmitted Electronically. Therefore, PLEASE PRINT this FORM, SIGN it where indicated, & BRING IT with YOU when you COME IN for your SCHEDULED APPOINTMENT.
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