To save time at your visit, New Patients can fill out the following information prior to their appointment with Dr. Bob.
Name
Email (required)
Sex MaleFemale
Birthdate
Marital Status SingleMarriedDivorcedWidowed
Home Address
City
State
ZIP
Home Phone
Work Phone
Cell Phone
Your Employer
Occupation
Employer's Address
Zip
Who referred you/How did you hear about us?
Insurance Company
Phone Number
Insurance Company Address
Subscriber's Name
Relation to Patient
Insurance Card ID #
Group Number
Subscriber's Employer
Have you ever been treated by a Chiropractor before? YesNo
If so, for what?
If you have pain today, please describe it
When did this condition begin?
Is it getting worse? YesNo
Does the pain radiate anywhere? YesNo
If yes, please describe
Is this condition ConstantComes & Goes
List all medications (prescription & non-prescription)
List any diseases which you have had in the past, including childhood diseases
Have you ever been diagnosed as having a particular condition such as diabetes, cancer, AIDS, etc? YesNo
If yes, please explain
Have you ever suffered any physical injuries such as whiplash, concussion or head injury, broken bones, or dislocation? YesNo
Check off any conditions you currently have or have had in the past. AIDSAlcoholismAnemiaAnorexiaAppendicitisArthritisAsthmaBleeding DisordersBreast LumpBronchitisBulimiaCancerCataractsChemical DependencyChicken PoxDiabetesEmphysemaEpilepsyGlaucomaGoiterGonorrheaGoutHeart DiseaseHepatitisHerniaHerpesHigh CholesterolHIV PositiveKidney DiseaseLiver DiseaseMeaslesMigraine HeadachesMiscarriageMononucleosisMultiple SclerosisMumpsPacemakerPneumoniaPolioProstate ProblemsPsychiatric CareRheumatic FeverScarlet FeverStrokeSuicide AttemptThyroid ProblemsTonsillitisTuberculosisTyphoid FeverUlcersVaginal InfectionsVenereal Disease
Are there any diseases that are common among your family members? (ie. inherited diseases or conditions? YesNo
Exercise NeverOccasionallyFrequentlyRegularly
Do you use Tobacco? YesNo
If yes, what type
Do you use consume alcohol? YesNo
If yes, SociallyOccasionallyFrequentlyRegularly
Height (feet)
Height (inches)
What is your current weight? (pounds)
Who is your primary Medical Doctor?
Address of primary Medical Doctor
Are you taking birth control pills? YesNo
Are you pregnant? YesNo
Date of last menstrual period
How would you describe your symptoms? AchySharpBurningStabbingPins & NeedlesNumbness
At its worst (0-10)
At its best (0-10)
On an average (0-10)
I, the undersigned, hereby authorize assignment of my (or my dependent) insurance rights and benefits directly to Robert W. Astapoveh, DC. for services rendered. I understand that I am financially responsible for all charges whether or not paid by my insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I hereby authorize the doctor/staff to perform any necessary services needed during diagnosis and treatment.
I understand the above information and guarantee this form was completed correctly and to the best of my knowledge. I further understand it is my responsibility to inform this office of any change in my medical status.
Relationship
Date
Responsible Party Signature
