Amesbarry - New Patient Welcome - Elite Secure Forms

Patient Information:

First Name *

Middle Name

Last Name *

Date

First name you prefer us to call you by:

Patient’s Date of Birth: *

Gender: *FemaleMale

Street Address, including Apt, Suite, etc. *

City *

State *

Zip *

Cell #: *

Home #:

Email Address: *

Parent or Guardian name if patient is a minor:

Name & phone # of emergency contact: *

Who referred you or how did you find out about us?

Your Employer Company Name:

City and State of Employer:

Have you been in an auto accident or work accident in the last 6 months?

If yes date:

Insurance Information

Skip to auto accident info if visit is due to auto accident.

Insurance Company:

Phone:

ID#:

Group/Account#:

2nd Insurance Company:

Phone:

ID#:

Group/Account#:

Auto Accident Insurance Information:

Date of Accident:

Did you inform your insurance company of accident?YesNo

Insurance Company:

Phone:

Claim #:

Attorney’s Name:

Phone:

Work Comp Injury Information:

Date of Injury:

Did you report this injury to your employer?YesNo

Employer/Manager Contact Name/Phone:

Insurance Co:

Phone:

Claim#:

Symptoms

What are you being seen for today? *0 / 220

When did you first experience symptoms? *

Has this condition progressively become worse?

Rate the severity of your issue (1 = mild discomfort, 10 = severe) *

What treatment have you received for this already?0 / 180

Name of Clinic(s) you have been to:0 / 240

Health History

List any surgeries and dates:0 / 220

Medications you take:0 / 220

Vitamins/Supplements you take:0 / 220

Women Only:

Daily Habits

What type of exercise do you do on a weekly basis? *None/very littleModerateHeavy

If you smoke, packs per week?

Amount of alcohol consumed weekly?

Amount of caffeine consumed daily?

General Consent to treat and Assignment of Benefits

I certify that if I and/or my dependent/s has insurance coverage, I request payment of authorized benefits from *directly to Amesbarry Chiropractic for services rendered.

Signature of Patient or Legal Representative: *

Date *

If signing for patient print your name & relationship: