For patient confidentiality reasons, we can not accept sensitive information through the Internet. Please enter your information into the spaces below, print it out and bring it to your first office visit. You can either hand write or type directly into the form.

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.

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
Are your RECREATION activities restricted?
Yes No

Past Medical History

Have you seen another doctor for this condition:
 
Previous Doctor of Chiropractic care?
 
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
Have you ever broken any bones?
Yes No
Do you have any congenital and or birth conditions?
Yes No

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:_________________


Advanced Spine and Sports Care
4552 N. Magnolia
Chicago, Illinois 60640
773-769-BACK (2225)
Copyright 2002-2008