State Line Chiropractic :: Providing Quality Care In Leawood, Kansas

Patient Information

Name

First Name:

MI:

Last Name:

Date:

Address:

City:

State:

Zip:

Phone:

Email Address:

Social Security #:

Sex:

Age:

Birthdate:

Are You...

Minor

Married

Divorced

Widowed

Single

Separated

Your Employer:

Work Phone:

Occupation:

City:

State:

Zip:

Spouse or Parent Name:

Work Phone:

Who May We Thank For Referring You?

Person To Contact In Case of an Emergency:

Phone:

Responsible Party

Person Responsible For This Account:

Relationship To Patient:

Phone:

Address:

City:

State:

Zip:

Work Phone:

Insurance Information

Relationship To Patient:

Birthdate:

Social Security #:

Work Phone:

City:

State:

Zip:

Symptoms

Reason For This Visit:

When Did You First Start
Feeling Symptoms?

Is This Condition Getting Progressively Worse?

Where Specifically Is The Problem Located?

Which Activites Are Difficult To Perform?

Sitting

Standing

Walking

Bending

What Type of Pain?

Sharp

Dull

Throbbing

Numbness

Aching

Burning

Tingling

Cramps

Stiffness

Swelling

Rate The Severity of Your Pain 1-10
(1= mild pain or discomfort/10= severe pain)

Is the pain constant or does it come and go?

What Treatment have you already received for your condition?

Medication

Surgery

Physical Therapy

Other

Names and addresses of other doctors who have treated you for this condition:

Health History

	AIDS/ HIV	Bronchitis
	Fractures	Kidney Disease
	Pinched Nerve	Alcoholism
	Bulemia	Glaucoma
	Liver Disease	Pnuemonia
	Allergy	Cancer
	Gonorrhea	Migraine Headaches
	Prostate Problems	Anemia
	Cataracts	Gout
	Miscarraige	Prosthesis
	Anorexia	Chemical Dependency
	Heart Disease	Mononucleosis
	Psychiatric Care	Appendicitis
	Chicken Pox	Hepatitis
	Multiple Sclerosis	Rheumatoid Arthritis
	Arthritis	Depression
	Hernia	Mumps
	Rheumatic Fever	Bleeding Disorders
	Asthma	Breast Lump
	Diabetes	Emphysema
	Epilepsy	Herniated Disk
	Herpes	High Cholesterol
	Osteoporosis	Pacemaker
	Parkinson’s Disease	Scarlet Fever
	Stroke

Date of Last Exam:
(Women) Are You Pregnent?
Nursing?
Taking Birth Control Pills?
List Any Surgeries and Dates:
Allergies?
List All Medications You Take:

Daily Habits

What type of exercise do you perform on a regular basis?

None

Moderate

Strenuous

What do your daily work habits include?
(sitting, standing, light or heavy labor, computer)

What vitamins do you take?

Other nutritional supplements?

Do you smoke?

How much per day?

How much liquor do you consume weekly?

How much coffee of other caffeinated beverages (soda, tea, etc.) do you consume daily?

Authorization

I understand and agree that health and accident insurance policies are an arrangement between the insurance carrier and myself. I authorize payment from my insurance carrier directly to this offi ce with the understanding that all monies will be credited to my account upon receipt. I clearly understand and agree that all services rendered to me are charged directly to me and I am personally responsible for payment. I understand that if I suspend or terminate my care or treatment, fees for professional services rendered to me will be immediately due and payable. In event of default, I promise to pay legal interest on the indebtedness together with collection costs and reasonable attorney’s fees as may be required to effect collection.

I hereby authorize Dr. Larry Holtfrerich and State Line Chiropractic Center to release any information, reports or copies of medical records which maybe requested by any insurance company or medical doctor’s office.

Patient Signature:

Date: