Acct#________________ Provider#______________ FC________ Fee__________ State________ D/I____________________

CONFIDENTIAL PATIENT INFORMATION

(Please Print)
Patient’s Name: _______________________________ ______________________ ____________________________
First Middle Last
Home Address: ____________________________ Apt#: ______ City: _______________ State: ______ Zip: _______

What do you prefer to be called: ______________________________________ SS#: _____________________

Home#: ______________________ Work#: _____________________ Cell#: _______________________

Marital Status: M S W D Date of Birth: _____/_____/_____ Age: ______ Sex: M F

Month Day Year

To receive monthly newsletter/special announcements, E-mail Address: ______________________________________

Employer’s Name: __________________________________ Occupation: ___________________________________

Work Street Address: ______________________________________ City: _____________ State: ______ Zip: ______

Employment Status: Full-Time Part-Time Self-Employed Retired Full-Time Student Part-Time Student

Spouse’s Name: ______________________________________ Spouse’s Employer: ___________________________

Contact in case of an emergency: __________________________ Relation: _______________ Phone#: ___________

Name of nearest relative not living with you: ________________________________________ Phone#: ____________

Relative’s Address: ______________________________ Apt#: ______ City: __________ State: ______ Zip: _______

Who referred you to our office? We’d like to thank them: _________________________________________________

Financial Information: (choose one)

Today I will be paying with ___ Cash ___ Check ___Credit Card for any fees not covered by insurance or any other 3rd party.
If patient is under 18 years of age:
I hereby authorize Dr. Chas B. Kubasko, Dr. Marc A. Burr, Dr. Christian D. Werness, Dr. Molly A. Leavitt, Tracy Flannelly, LMBT or whomever they may
designate as their assistant to administer treatment, including X-rays and examinations, necessary to treat ________________________________ at Crabtree
Chiropractic Center. Minor’s Name

__________________________________
Signature of Parent or Legal Guardian

I authorize Crabtree Chiropractic Center to release any information it deems appropriate concerning my physical condition to any insurance
company, adjuster, or attorney in order to process my claim for reimbursement of charges incurred by me as a result of professional services
rendered by Crabtree Chiropractic Center. I also authorize Crabtree Chiropractic Center to release any information it deems appropriate
concerning my physical condition to my medical doctor.
I acknowledge that upon request I will be given the Notice of Privacy Practices of Crabtree Chiropractic Center PA, which describes the
Practice’s policies and procedures regarding the use and disclosure of any of my Protected Health Information created received or maintained
by the Practice. I consent to Crabtree Chiropractic Center’s use and disclosure of my Protected Health Information (any information, including my
demographic information, created or received by the Practice, that relates to my past, present or future physical or mental health or condition; the provision of
health care tome; or the past, present, or future payment for the provision of healthcare services to me; and that either identifies me or from which there is a
reasonable basis to believe the information can be used to identify me) for the purpose of providing treatment to me, for purposes relating to the
payment of services rendered to me, and for the Practice’s general healthcare operations purposes.

I have received, reviewed, understand and agree to the Financial Policy of Crabtree Chiropractic Center PA.

________________________________________ ___________________ When complete, please bring this sheet

Signature of Patient Date to the front desk then proceed
with completing the remaining forms.
 CURRENT COMPLAINT

This visit is a result of: ___ Auto Accident (_________________) ___ Work Injury (________________) ____ Other
month / day / year of accident month / day / year of accident
Explain what happened: ____________________________________________________________________________

Draw on the man where you have your problem(s):

When did symptoms appear (be specific: mo./day/year)? _____________

Who have you seen for this problem/condition?

Who When Treatment
□ No one _____________ ______________
□ Chiropractor _____________ ______________
□ Medical Doctor _____________ ______________
□ Physical Therapist _____________ ______________
□ Other: __________ _____________ ______________

Have you ever been to a chiropractor? NO YES If yes, who: __________________________When: _____________

List days off work due to this problem: ________________________________________________________________

Have you ever had this exact same problem before? NO YES If yes, when: _________________________________

Have you had a bone density test? NO YES If yes, Approximate date: Mo/Yr: ___________ Results: ___________

Your Family Physician (M.D.): ______________________________________ Location: _______________________

Major surgeries with approximate dates: _______________________________________________________________

Significant injuries& diseases with approximate dates: ___________________________________________________

________________________________________________________________________________________________

Check all that apply to you: Are you currently having problems with:
N/A Mild Moderate Significant Swallowing Yes No Dizziness/ Vertigo Yes No
( ) ( ) ( ) ( ) Exercise Speech Yes No High Blood Pressure Yes No
( ) ( ) ( ) ( ) Tobacco Stroke/ TIA Yes No Double Vision Yes No
( ) ( ) ( ) ( ) Alcohol Bruising Yes No Vomiting Yes No
( ) ( ) ( ) ( ) Caffeine Sudden Numbness or weakness of face/arm/leg Yes No

Mark appropriate box if direct blood relative has or has had any of the following:
( ) Cancer ( ) Rheumatoid Arthritis ( ) Chronic Back Problems ( ) Heart Problems ( ) Lung Problems ( ) High Blood Pressure
( ) Lupus ( ) Epilepsy ( ) Chronic Headaches ( ) Other Serious Conditions: ___________________________________________
___________________________________________________________________________________________________________________

Your Height: _________ feet _______ inches Your Weight: __________ pounds

Females only: Are you pregnant? NO YES If Yes, Due date: _____________________

Patient remarks or additional information: _____________________________________________________________

________________________________________________________________________________________________
Doctor’s Notes: __________________________________________________________________________________
________________________________________________________________________________________________

Patient’s Name: ___________________________________________ Date: _______________________