Name:
Date of Birth:
Address:
City:
Zip:
Where Employed:
Home Phone:
Work Phone:
Cell Phone:
Marital Status:	Married Single Widow(er) Separated Divorced
Present Health Problems: In order of importance, please list the complaints in which you are seeing the chiropractor
Is this condition related to an accident?:	Yes No
Date of accident:
What doctors have you seen for this?
Progress:	Better Worse Same
What makes this condition worsen?
Have you ever been hospitalized?
Surgeries?
Cracked or broken bone?
Personal habits?	Smoking Alcohol Vitamins Exercise Medications
Date of last menstrual cycle?
Are you currently pregnant?	Yes No
How were you referred to our office?
Name of Insurance Company:
Card Holder Name:
Date of birth:
Relationship to cardholder:
Place of employment:
In order to maximize your treatment at Goldsboro Spine Center, group therapy is required as part of the treatment process. Disclosure of Private Health Information is required in order to carry out this procedure. A signature below states you release the use of that information under HIPPA guidelines. Information is sometimes requested from Health insurance companies. A formal written request will be forthcoming before any information is released. For patient protection and for training purposes you may be observed by video monitoring or another experienced chiropractor in the exam, treatment or therapy rooms. A signature will authorize your consent as well as all payments from insurance companies to be paid directly to Goldsboro Spine Center or Goldsboro Spinal Care and Rehab. This consent can be reviewed at any time, and is revocable upon written request.