Chiropractic First! PLLC.
Chiropractic First! PLLC.
Please complete all questions. If the questions do not apply to you write n/a in the space
Name___________________________ Birth date_______________Marital Status S M W D
Address__________________________ City ____________________ State_____ Zip_______
Home#______________________Work#____________________Cell#____________________
Social Security Number:______________________ Drivers License #___________________
Who is your employer_____________________
Who can we contact in case of emergency? Name_______________________
Phone hm____________ work_______________ Relationship__________________________
How did you hear about our office? _______________________________
Is this your first visit to a Chiropractor? Yes or No if no when was your last chiropractic treatment?_____________________________
Insurance Information
Do you have Health Insurance? Yes or No
Name of Insurance Company_________________________ Policy #_____________________
Policy Holder________________________ Policy Holders Employer_____________________
Policy Holder’s Birthdate_________________________ Group # _______________________
Health Information
What is your major complaint today?_______________________________________________
What medication are you currently taking?__________________________________________
Please list all of the surgeries you have had___________________________________________
Accident?
Is your condition due to an accident Yes or No if yes date of accident____________________