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ONLINE Chiropractic New Patient Case History

ONLINE Chiropractic New Patient Case History

(215) 256-8006 Schedule your visit

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Patient Center

Please make sure to complete the required (*) questions.

This form WILL NOT be submitted unless all required (*) questions are answered.

Today's Date*

First Name*

Last Name*

Patient Type

Email: For appointment reminders and office announcements *

Phone*

If Cell number, who is your CARRIER?

Preferred Date*

Preferred Time Of Day

Comments

Address*

Address

City*

State *

Zip*

Birthdate*

How did you find out about our office?

Your Occupation

Employer

Spouse's Name

Please Describe Current Complaint *

Date Problem Started *

Have you ever had same condition?

No Yes

If yes, when?

List other practioners seen for this injury/condition

Have you ever been under chiropractic care?

Yes No

Approximately when?

What are your Health Goals?

Insurance Information for Chiropractic Care.

Injury, but not related to work or auto No known injury We do not submit for Work Comp or Auto Accident

Will you be using health insurance?

Yes No

Name of insurance company

ID Number

Name of party responsible for payment and their date of birth*

Insurance company name

Contact person

Phone

Claim #

Health History

Have you been treated for any conditions in the last year?

No Yes

If yes, please describe

Have you had X-rays taken?

Yes No

If Yes, name of facility? (Please bring reports if able)

If female: Is there a chance that you are pregnant?

No Yes

What medications are you taking and for what conditions

What vitamins, minerals, or herbs do you currently take?

Have you ever:

Briefly Explain

Had Sprains/Strains?

No Yes

Briefly explain

Been struck unconscious?

No Yes

Briefly explain

Had Surgery?

No Yes

Briefly Explain

Habits

Exercise

None Light Moderate Heavy

Sleep

None Light Moderate Heavy

Water

None Light Moderate Heavy

Have you ever suffer from:

Alcoholism Allergies Anemia Arteriosclerosis Arthritis Asthma Back Pain Breast Lump Bronchitis Bruise Easily Cancer Chest Pain Cold Extremities Constipation Concussion Cramps Depression Diabetes Digestion Problems Dizziness Ears Ring/Tinnitus Excessive Menstruation Eye Pain Fatigue Frequent Urination Headache High Blood Pressure Hot Flashes Irregular Heart Beat Irregular Cycle Kidney Infection Kidney Stones Loss of memory Loss of balance Loss of smell Loss of taste Lumps In Breast Migraines Neck Pain or Stiffness Nervousness Nosebleeds Pacemaker Poor Posture Prostate Trouble Sciatica Shortness of breath Sinus Infection Sleep problems Spinal Curvatures Stroke Swelling of ankles Swollen Joints Thyroid Condition Varicose Veins Vertigo

Anything else we should know?

Please describe

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

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CONTACT US

We hope to see you soon

Family Chiropractic of Lederach, LLC

658 Harleysville Pike Suite 110,
Harleysville, PA 19438 US

Monday:

8:00 am - 12:00 pm

3:00 pm - 6:00 pm

Tuesday:

3:00 pm - 6:00 pm

Wednesday:

8:00 am - 12:00 pm

3:00 pm - 6:00 pm

Thursday:

10:00 am - 12:00 pm

3:00 pm - 6:00 pm

Friday:

Closed

Saturday:

Closed

Sunday:

Closed

Name*

Email *

Phone *

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

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Location

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Family Chiropractic of Lederach, LLC

Address

658 Harleysville Pike Suite 110
Harleysville, PA 19438, US

Contact Information (215) 256-8006

[email protected]

Address
658 Harleysville Pike Suite 110,
Harleysville, PA 19438

Phone
(215) 256-8006

Email
[email protected]

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