New Patient Forms

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General Info

Patient Name:

Today's Date:

Home Address:

City:

State:

Zip Code:

Home Phone:

Cell Phone:

Email Address:

DOB:

ID #:

SSN#:

Emergency Contact:

Relationship to Patient:

Home Address:

Home Phone:

Cell Phone:

Email:

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Employment Info

Employment Info

Student

Other

Employer/School:

Work Address:

City:

State:

Zip Code:

Work Phone:

Ext:

Work Email:

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Health Insurance Info

Name of Insured:

Insurance Provider:

PPO

HMO

Medicare

Other

ID #:

Policy #:

Group #:

Insurance Phone # (on back of card):

Primary Physician:

Phone #:

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Party Responsible for account

Above Patient is Responsible - or - Name:

Relationship to Patient:

Home Address:

Home Phone:

Cell Phone:

Email:

DOB:

ID #

SSN#:

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Medical Information

Age:

Height: feet=

Inches=

Weight:

Date of last Medical Exam:

Doctor's Name"

Recent medical procedures:

Results:

ALL Prescribed Medications:

ALL Over-the-Counter Medications:

Known congenital (from birth) factors that relate to your condition?

Previous illnesses/complications from previous injuries?

Yes

Hospitalizations or surgeries? Including childhood?

Yes

Is there any chance you may be pregnant?

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Check ALL that apply to you:

Loss of consciousness/ head Injuries

Yes

Seizures/epilepsy/convulsions

Yes

Dizziness/fainting

Yes

Visual disturbances/eye problems

Yes

Nose. Throat, breathing problems

Yes

Asthma, allergies, allergic reactions

Diarrhea, constipation

Numbness In groin/buttocks/legs/feet

Yes

Abnormal/rapid weight gain/loss

Yes

High blood pressure

Yes

Artificial joints

Yes

Night sweats

Pain at night

Yes

Pain unrelieved by position/rest

Yes

Morning pain/stiffness

Yes

Lupus

Yes

Diabetes

Yes

Pacemaker

Yes

Hernia

Yes

Osteoporosis

Yes

Sleep apnea/sleep conditions

Yes

Menstrual problems

Yes

Urinary/bladder control problems

Yes

Recent fever

Corticosteroid - cortisone, prednisone

Yes

Birth control pills

Pain killers/muscle relaxants

Yes

Alcohol/tobacco/drug abuse

Yes

Rheumatoid arthritis

Yes

Blood disease:

Stroke - date:

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Social Hostory - Check ALL that apply to you:

Daily work/home habits

prolonged sitting/standing

Heavy lifting

Poor posture

Other

Daily Work Habits

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Patient Health Information

Patient Health Information

Injury Care

Temporary relief care

Preventative/correction care

Wellness care

When did you injure yourself? Date

What are your health goals? (Check all that apply)

Reduce/eliminate pain

Reduce stress/tension

Manage weight/diet

Manage diet/nutrition

Increase strength/flexibility

Increase energy

Maintain health

Other

What services are you seeking?

Chiropractic

Massage Therapy

Mechanical traction

Physiotherapy

Rock tape

Medications

Exercise education/prescription

Sports physical

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What are your areas of concern? (Check ALL that apply)

Headache: /10

Jaw Pain: /10

Neck Pain: /10

Upper back pain: /10

Mid-back Pain: /10

Low back pain: /10

Chest: /10

R/L Shoulder: /10

R/L Elbow: /10

R/L Wrist: /10

R/L Hand: /10

R/L Upper Arm: /10

R/L Forearm: /10

Abdomen: /10

R/L Thigh: /10

R/L Hip: /10

R/L Knee: /10

R/L Foot: /10

R/L Ankle: /10

R/L Upper Leg: /10

Lower leg: /10

Other:

What makes your condition worse?

Is your condition becoming progressively worse?

Yes

Have you previously received treatment for this condition?

How long have you had this condition? Since (month/day/year):

# Hours

# Days

# Weeks

# Months

# Years

Does your pain travel/radiate to another area of your body?

Has your condition interfered with your

daily activities

work

house duties

sports

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Urteaga Chiropractic Policies, Terms & Conditions

Opt-In

If I fail to attend my scheduled appointment without cancellation notice 24 hours prior, I agree to pay a $25

no show/late cancellation fee.

Opt-In

I am responsible & directly liable for payment of any outstanding balances. Any deductibles, co-payments,

co- insurance or other fess for any office service rendered are payable at the time of my visit, unless other arrangements have been

made & agreed upon prior to treatment.

Opt-In

I agree to notify the office promptly of any changes to my health insurance policy, or other pertinent information.

Opt-In

I have and will notify the office of any previous auto/work related injuries that I may suffer hereafter.

Opt-In

A $25 fee will be charged for all returned checks.

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Authorization & Assignment

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I give authorization to this office to contact my primary care physician and/or relevant health care providers & specialists regarding co-

management of my health. I request & authorize direct payment of any medical or automotive insurance company benefits or any

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Informed Consent

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I hereby request and consent to the consultation, examination, performance of chiropractic adjustments and related chiropractic

procedures on patient named below for which I am legally responsible, by the doctor or intern directly supervised by doctor, as

needed. Results are not guaranteed and there is no promise to cure any health condition. I understand that there are some risks

to treatment, including but not limited to muscle soreness, spasms, sprains, strains, dislocations, disc injuries, fractures and strokes,

most with extremely rare incidence. I do not expect the provider to be able to anticipate and explain all risks and complications. I wish

to rely on the provider to exercise judgment during the course of the procedures which the provider feels at the time, based on the

facts then known, is in my best interest. The provider will not be held responsible for any pre-existing medically diagnosed conditions

nor for any medical diagnosis. I agree to inform staff of any pre-existing conditions, limitations, specific sensitivities or discomfort at

any time. I have read the above consent and I understand that I can ask the doctor and staff at anytime regarding any risks or

concerns. Any questions, comments, or complaints may be brought to the attention of staff. By signing below, I agree to the above,

and allow the provider or supervised chiropractic intern affiliated with Urteaga Chiropractic to perform such as described above. I

intend this consent form to cover the entire course of treatment for my present condition and for any future conditions for which I

seek treatment. Urteaga Chiropractic is not responsible for lost or stolen articles or items.

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