To save time at your visit, New Patients can fill out the following information prior to their appointment with Dr. Bob.

Patient Information

Sex
MaleFemale

Marital Status
SingleMarriedDivorcedWidowed


Insurance Information


Reason for Visit

Have you ever been treated by a Chiropractor before?
YesNo

Is it getting worse?
YesNo

Does the pain radiate anywhere?
YesNo

Is this condition
ConstantComes & Goes


Past History

Have you ever been diagnosed as having a particular condition such as diabetes, cancer, AIDS, etc?
YesNo

Have you ever suffered any physical injuries such as whiplash, concussion or head injury, broken bones, or dislocation?
YesNo


Review of Systems


Family/Social History

Are there any diseases that are common among your family members? (ie. inherited diseases or conditions?
YesNo

Exercise
NeverOccasionallyFrequentlyRegularly

Do you use Tobacco?
YesNo

Do you use consume alcohol?
YesNo

If yes,
SociallyOccasionallyFrequentlyRegularly

This section is for women only

Are you taking birth control pills?
YesNo

Are you pregnant?
YesNo


Pain Description & Pain Scale

How would you describe your symptoms?
AchySharpBurningStabbingPins & NeedlesNumbness

Please rate your pain on a 0-10 scale (with 0 representing no pain and 10 representing extreme pain)


Assignment, Release and Consent

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.