Please print this form, fill it out, and bring it to our office on the day of your first appointment. If you have any questions, please feel free to call us. CONFIDENTIAL PATIENT INFORMATION Name (First/MI/Last)_________________________________________ DOB__________ Age_____ Sex M F Home Address_______________________________________________________________________________________ City______________________________ State_____ Zip____________ SS #____________________________________ Home Phone______________________ Cell Phone______________________ Work Phone________________________ E-Mail_____________________________ Marital status: M S W D Children____________________________________ Occupation_________________________ Employer____________________________________________________________ Spouse Name_______________________ Age____ Occupation________________ Work Phone______________________ How is this account to be paid (circle one): Self Health Insurance Medicare Auto Accident Workers’ Comp. Other___________________ Referred by_____________________________________________________________________________________ PAYMENT EXPECTED AT TIME OF VISIT UNLESS OTHER ARRANGEMENTS ARE MADE CURRENT HEALTH CONDITION Purpose of this appointment___________________________________________________________________________ When did this condition begin?__________________________________________________________________________ What activities make symptoms worse?___________________________________________________________________ What activities make symptoms better?_____________________________________________________________________ Symptoms worse in (circle): Morning Day Evening Night Better in (circle): Morning Day Evening Night Symptoms (circle): come and go came on gradually came on suddenly Dates_______________ Duration of symptoms: _____days _____weeks _____months _____years Disabled from work (dates):______________________ Job related: Y N Auto related: Y N Current medications:_________________________________________________________________________________ Other Doctors seen for this condition_______________________________________________________ DC DO MD If Female, are you pregnant? Y N Date of last period______________ PAST HISTORY Date of last Physical______________ Reason____________________________________________________________ Major accidents/falls_________________________________________________________________________________ Other health concerns_______________________________________________________________________________ Previous Chiropractic care: Y N Dates / Dr.______________________________________________________ I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that MERIDIAN VALLEY CHIROPRACTIC (MVCC) will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to MVCC will be credited to my account upon receipt. However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. Any accounts that are referred for collection will have a service fee charged at the time of referral to cover additional handling costs. Should legal action be necessary for the recovery of any monies due under this agreement, the prevailing party shall be entitled to recover attorney fees and court costs from the other party. It is not our intention to cause you undo hardship; however, we must collect our receivables as efficiently as possible in order to continue our service to the community. Interest of 1% per month will be charged on delinquent accounts. If you discontinue your care, all charges are due and payable immediately. Patient’s Signature_____________________________________ Driver License #______________________________ Guardian/Spouse Signature_____________________________________________ Date_________________________ REVIEW OF SYSTEMS Please write in a number: 1. PRESENTLY HAVE; 2. PREVIOUSLY HAD; 3. RELATED TO ACCIDENT (Date: ______) GENERAL MUSCULOSKELETAL CARDIOVASCULAR ___Allergy ___Arthritis ___Hardening of arteries ___Chills ___Bursitis ___High blood pressure ___Convulsions ___Foot Trouble ___Low blood pressure ___Dizziness ___Hernia ___Pain over heart ___Fainting ___Low back pain ___Poor circulation ___Fatigue ___Lumbago ___Rapid heart beat ___Fever ___Neck pain/stiffness ___Slow heart beat ___Headache ___Shoulder blade pain ___Swelling of ankles ___Sleep loss Pain or numbness in: RESPIRATORY ___Weight loss ___ Shoulders ___Chest pain ___Nervousness/depression ___ Arms ___Chronic cough ___Neuralgia ___ Elbows ___Difficult breathing ___Numbness ___ Hands ___Spitting up blood ___Sweats ___ Hips ___Spitting up phlegm ___Tremors ___ Legs ___Wheezing EYES, EARS, NOSE, THROAT ___ Knees GASTROINTESTINAL ___Asthma ___ Feet ___Belching or gas ___Colds ___Painful tailbone ___Colitis ___Sore throat ___Poor posture ___Colon trouble ___Deafness ___Sciatica ___Constipation ___Dental decay ___Spinal curvature ___Diarrhea ___Earache/noises GENITO-URINARY ___Difficult digestion ___Ear discharge ___Bedwetting ___Distention of abdomen ___Sinus infection ___Blood in urine ___Excessive hunger ___Enlarged glands ___Frequent urination ___Gall bladder trouble ___Enlarged thyroid ___Inability to control bladder ___Hemorrhoids ___Nose bleeds ___Kidney infection or stones ___Intestinal worms ___Failing vision ___Painful urination ___Jaundice ___Far sighted ___Prostate trouble ___Liver trouble ___Gum trouble ___Pus in urine ___Nausea ___Hay fever ___Painful menstruation ___Pain over stomach ___Hoarseness ___Hot flashes ___Poor appetite ___Nasal obstruction ___Irregular cycle ___Vomiting ___Near sighted ___Lumps in breasts ___Vomiting blood OTHER:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Adobe Acrobat Reader is needed to view PDF forms. If you need this, you can download a free version by clicking:     Form Name Form File   Activities of Daily Living Assessments Neck Pain   Meridian Valley Chiropractic, along with all information provided, is for educational purposes only and is not an attempt to replace the need to seek healthcare services or to provide specific healthcare advice. We strongly encourage users to consult with their chiropractor or other qualified healthcare professionals for personal healthcare attention and answers to personal questions. Meridian Valley Chiropractic 13106 S.E. 240th St., Suite 201 Kent, WA 98031 www.hugheschiro.com Michael Hughes, DC E-Mail: mvcc92@gmail.com Phone: 253-631-1118 Fax: 253-631-1156   © 2001-2003 Healthy Practices, Inc. All rights reserved.