Patient Forms

Please fill out our Health Record as completely and accurate as possible. If you have any questions, please don't hesitate to ask one of our qualified Chiropractic Assistants.
It is our pleasure to be of service to you. Our commitment to you is to promote the highest quality of health and well-being with Chiropractic care.

About You

First Name*
Last Name*
Street Address*
City*
State/Province*
Zip Code*
Cell Phone*
Phone
Birthday*
Gender
Social Security #*
Email*
Employer*
Type of Work*
Marital Status*

My Health Insurance

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. I understand that the Doctor's Office will provide any necessary reports and forms to assist me in collecting from the insurance company and that any amount authorized to be paid directly to the Doctor's Office will be credited to my account upon receipt.

We verify your insurance information as a courtesy to our patients, However, it does not constitute financial liability on our end. We highly recommend contacting your insurance to know your benefits and what your insurance may and may not cover.

Reason For This Visit

Is the purpose of this appointment related to:*
Please explain.
If job related, have you made a report of your accident to your employer?
When did this condition begin?
Has this condition
Does this condition interfere with
Has this condition occurred before?
Have you seen other doctors for this condition?
Doctor's Name(s)
Results

Health Habits

Do you smoke?*
Do you drink alcohol?*
Do you drink caffeine?*
Do you exercise regularly?*

Health Conditions

Please check each of the diseases or conditions that you have had now or in the past. While they may seem unrelated to the purpose of the appointment, they can affect the overall diagnosis, care plan and coordination of care with other healthcare providers.

Surgical History
Please list past surgeries and approximate year surgery was performed.
Please list any allergies.
Family Health History*
Please explain relation and age at death of parents and/or siblings:
Medications I Now Take:
Please list any medications and /or vitamins you are currently taking

Review Of Systems

Pulmonary (lung-related) issues?*
Cardiovascular (Heart-related)*
Neurological (Nerve Related)*
Endocrine (glandular/hormonal)*
Renal (kidney-related)*
Gastroenterological (stomach-related)*
Hematological (blood-related)*
Dermatological (skin-related)*
Musculoskelatal (bone/muscle-related)*
Psychological*
Please explain any of the boxes checked
Is there anything else in your past medical history that you feel is important to your care here?

For Women Only

Are you pregnant?
Are you nursing?
Are you taking birth control?
Do you have irregular cycles?
Do you have breast implants?

Initial Consultation Form

Primary Complaint (s):
Overall frequency of complaint (Please select only one)
Overall intensity of complaint (Please select only one)
Is this problem affecting any other area of your body? If yes, please explain:
Does it interfere with your normal daily activities (Family, recreation, sports)?
What aggravates the problem?
What relives the problem?
Patient's Signature
Date

Insurance:

We will verify all insurances and your benefits per your agreement with your carrier. After verification, the Doctor will give his recommendations and an appropriate plan will be designed for each individual. Please let the front desk know if you have been in some type of accident or have been injured on the job. This will enable us to give you any and all information necessary to serve you completely and accurately.

Agreement:

My signature below signifies my agreement for payment in full on a cash basis if I have not provided all the necessary documents and information by the time of the second visit.

I have read and agree to the above statement.

Patient Signature
Patient Name (printed)
Date
Witness
Roya1234 none chiropractor # # # 10956 Warner Avenue
Fountain Valley, CA 92708 7147983308 7149635775 drscott789@gmail.com 9:00 AM - 12:30 PM 3:30 PM - 6:30 PM 9:00 AM - 12:30 PM 3:30 PM - 6:30 PM 9:00 AM - 12:30 PM 3:30 PM - 6:30 PM 9:00 AM - 12:30 PM 3:30 PM - 6:30 PM 9:00 AM - 12:30 PM 3:30 PM - 6:30 PM Appointment Only Closed 9741 Bolsa Ave Suite #118
Westminster, CA 92683 7148398144 drscott789@gmail.com 10:00 AM - 2:00 PM 9:00 AM - 6:00 PM 9:00 AM - 6:00 PM 9:00 AM - 6:00 PM 9:00 AM - 6:00 PM 9:00 AM - 6:00 PM 9:00 AM - 6:00 PM