Skip to main content

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 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.