CoreCare Chiropractic

630 N Cotner Blvd Suite 201, Lincoln, NE 68505

Phone:

402-325-0170

Patient Information:
Date First Name Sex Married/Civil Union: Home # Address City Emergency Contact Email State Emergency Relation Zip Emergency Phone Male Female SSN Middle Name Height Spouse Name Cell # Birthday Last Name Weight # of Children Work #

Patient Symptoms:

Patient Social
Alcohol: Diet Food Products: OTC Stimulants: Homemade Food: Soft Drinks: Water: Daily Daily Daily Daily Daily Daily Weekly Weekly Weekly Weekly Weekly Weekly Occasionaly Occasionaly Occasionaly Occasionaly Occasionaly Occasionaly Never Never Never Never Never Never Caffeine: Drugs: Exercise: Processed: Tobacco: Daily Daily Daily Daily Daily Weekly Weekly Weekly Weekly Weekly Occasionaly Occasionaly Occasionaly Occasionaly Occasionaly Never Never Never Never Never

Referral Information:
Referring Physician: Advertisement: Referred Directory: Yes Yes No No Referred Patient: Advertisement: Referred Directory: Referred by

Chiropractic Experience:
Who referred you to our office: Where did you hear about us? Newspaper Sign Yes Yellow Pages No If yes, Why? Approximate Date of Visit Mailing Community Event Other

Have you been adjusted by a chiropractor before?

Doctor's Name:

Employer Information:
Employed: Employer Address: Employer City: Occupation: Work Duties: Employer State: Work Supervisor: Employer Zip: Supervisor #: Employer Name

Reason for this Visit:

Describe the reason for this visit?

When did this concern begin? Does this concern interfere with: Briefly Explain: Has this concern occurred before? Briefly Explain: Have you seen other doctor's for this concern? Type of Treatment: Yes No Yes No Work Sleep

Has this concern: Daily Routine

Gotten Worse Other Activities

Stayed Constant

Come and Gone

Doctor's name:

Complaint Information:
Injury Occurred: Injury Origin: Desc Discomfort: Interfere w/ Activities: Missed Work: Affected Appetite: Reduced Work: Does it Worsen: Weather Affects it: Aggravates Condition: Improves Condition: Received Treatment: X-rays Taken: Same Condition Before: Yes Yes Yes No No No Explain: Explain: Date: Practitioner: Yes Yes Yes Yes Yes Yes No No No No No No Affected Sleep: Unable to Work from: Explain: Explain: Explain: Explain: Yes No Frequency: Unable to Work Until: Work Automobile Third-Party Other Injury Date:

For Women Only:

Are you pregnant? Are you nursing? Yes Yes No No Are you taking birth control? Do you experience painful periods? Yes Yes No No Do you have irregular cycles? Do you have breast implants? Yes Yes No No

Insurance Information:
Payment Name Payment Address Payment City Primary Group # Secondary Name Secondary Address Secondary City Secondary Group # Claim # Attorney Name Secondary State Secondary Name Claim Contact Attorney Phone # Secondary Zip Secondary DOB Claim # Payment State Primary Name Secondary Phone # Payment Zip Primary DOB Secondary ID/Policy Primary Phone # Primary ID/Policy

Goals for Your Care

People see a chiropractor for a variety of reasons. Some go for relief of pain, some to correct the cause of pain and others for correction of whatever is malfunctioning in their body. Your doctor will weigh your needs and desires when recommending your care program. Please check the type of care desired so that we may be guided by your wishes whenever possible. I want the Doctor to select the type of care appropriate for my condition Relief care: Symptomatic relief of pain or discomfort. Corrective care: Correcting and relieving the cause of the problem as well as the symptom Comprehensive care: Bring whatever is malfunctioning in the body to the highest state of health possible with Chiropractic Care

Personal Health History

Last Physical Exam: Phys City: Health Conditions: Previous Chiro Care: Chance Pregnant: Medications: Supplements: Yes Yes No No Date: Planning: Yes No Condition(s) treated: Primary Phys: Phys State: Phys Phone #: Phys Zip:

Were you aware that...

Chiropractic is the largest natural healing profession in the world? The nervous system controls all bodily functions and systems? Yes Yes No No Doctor's of Chiropractic work with the nervous system? Yes No

Personal Incident History:

Broken Bones: Sprains/Strains: Hospitalized: Surgery: Auto Accident: Struck Unconscious: Eating Disorder: Stroke: Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No Treatment: Treatment: Explain: Explain: Treatment: Treatment: Explain: Explain: Yes Yes No No Explain Explain Yes Yes No No Explain Explain

Health Checklist:
Allergies Arteriosclerosis Back Pain Bruise Easily Cold Extremities Depression Dizziness Fatigue Hemorrhoids Irregular Heart Beat Kidney Stones Loss of Smell Pacemaker Prostate Trouble High Blood Pressure Spinal Curvatures Swollen Joints Ulcers Alcoholism Arthritis Breast Lump Cancer Constipation Diabetes Excessive Menstruation Frequent Urination Venereal Disease Irregular Menstrual Loss of Memory Loss of Taste Polio Sciatica Sinus Infection Stroke Thyroid Condition Varicose Veins Anemia Asthma Bronchitis Chest Pain Cramps Digestion Problems Eye Pain or Difficulties Headache Hot Flashes Kidney Infection Loss of Balance Nosebleeds Poor Posture Shortness of Breath Insomnia Swelling of Ankles Tuberculosis

Family Health History:

Family Health History

EHR Information:
Pefered Language Ethinicty Current Medications And Dosage Smoking Status Race I choose to decline receipt of my clinical summary after every visit

Medication Allergies

I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.

Signature

Date: