General Information
Name:
Date of Birth:	MM/DD/YYYY
Address:
City:
Zip:
Where Employed:
Home Phone:
Work Phone:
Cell Phone:
Marital Status:	Married Single Widow(er) Separated Divorced
Insurance Information
Name of Insurance Company:
Card Holder Name:
Date of birth:
Relationship to cardholder:
Cardholder's Place of employment:
Present Health Problems
Present Health Problems: In order of importance, please list the complaints in which you are seeing the chiropractor
Is this pain due to an accident?:	Yes No
Date of accident:
Pain Information
Patient Name:
Have you ever had any pain like this before?	Yes No
If so: when?
Does it radiate anywhere (up, down, left, or right?)
Have you seen any other Drs. for this pain?	Yes No
If so: whom did you see?
How long ago did you see him/her?
what is the progress of the pain?	Better Worse Same
What is the pain on a scale of 1-10 when the pain is the worst: (with 10 being the worst)?	10 9 8 7 6 5 4 3 2 1
Describe the pain please: (throbbing, stabbing, burning, numb, dull ache.)
Does anything make it feel better? (Ice, Heat, Massage, Tylenol, Ibuprofen, Excedrin, Aleve, or others)
If so: what have you tried?
Does anything make it feel worse (specific movements, sleeping or work posture, activities, etc)
When does the pain bother you? (select all that apply)	Night Day Constant Occasionally Daily Weekly
Has your pain caused you to miss any work or school?	Yes No
If so: how much?
Are you taking any medications?
If so: how much and how often?
Have you ever been hospitalized?	Yes No
If so: when and why?
Have you had any surgeries?	Yes No
If so: when and what surgeries?
Personal Habits
Smoker?	Yes No
If so: how much, how often?
Alcohol?	Yes No
If so: how much, how often?
Vitamins?	Yes No
If so: how much and what kind?
Exercise?	Yes No
If so: how much and what kind?
Date of last menstrual cycle?
Are you currently pregnant?	Yes No
How were you referred to our office?
*Following today’s consultation, if the doctor feels you can benefit from chiropractic care, he/she will make specific recommendations for examination procedures in order you fully understand your condition. At the completion of your examination, you will be scheduled for a separate appointment for the doctor to review these findings with you and make recommendations for your care. We are committed to providing you with the best chiropractic care possible in a caring environment, and have established financial policies consistent with that goal. You are expected to pay for your chiropractic care at the time service is rendered unless other arrangements are made in advance. Details of available investment options will be discussed with you when the doctor goes over your specific recommendation for care during your report of findings, which will typically be scheduled on our next business day. You are responsible for any and all expenses incurred in the collection of any overdue account. There will be a $25 returned fee for any returned checks. We reserve the right to charge our typical adjustment fee for missed appointments without prior notification. X-rays remain property of this office and cannot be released. **In order to maximize your treatment at the Goldsboro Spine Center, PLLC, 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 that you release the use of that information under HIPPA guidelines. A signature will also authorize your consent to release your health information to your insurance company, which allows them to make any contributions to your care directly to Goldsboro Spine Center, and gives us limited power of attorney to endorse any check made out to you for services rendered by our office to you or on your behalf.