To save time at your visit, New Patients can fill out the following information prior to their appointment with Dr. Bob.
Who referred you/How did you hear about us?
Insurance Company Address
Relation to Patient
Insurance Card ID #
Have you ever been treated by a Chiropractor before?
If so, for what?
If you have pain today, please describe it
Where did this condition begin?
Is it getting worse?
Does the pain radiate anywhere?
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?
If yes, please explain
Have you ever suffered any physical injuries such as whiplash, concussion or head injury, broken bones, or dislocation?
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?
Do you use Tobacco?
If yes, what type
Do you use consume alcohol?
What is your current weight? (pounds)
Who is your primary Medical Doctor?
Address of primary Medical Doctor
Are you taking birth control pills?
Are you pregnant?
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.
Responsible Party Signature
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