Chiro-Associates

Step 1 of 2

50%

• Do you have an appointment?
  • Yes
  • No

• Patient Information

• First Name
• Last Name
• Date of Birth
  
  Date Format: MM slash DD slash YYYY
  
• Address
• City
• StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific
• Zip
• Social Security #
• Sex
  • Male
  • Female
  • Gender non-conforming
• Marital Status
  • Single
  • Married
  • Widowed
  • Divorced
  • Child (Under 18)
• Home Phone
• Cell Phone
• Work Phone
• Cell Carrier
• Email
  
• I consent to receive communication via texting/email from Chiro-Associates
  • Yes
  • No
• Ethnicity
  • Non-Hispanic
  • Hispanic
• Race
  • Asian
  • Black
  • Caucasian
  • Hispanic
  • Native American
  • Other
• Employment Status
  • Employed
  • Part-time Student
  • Full-time Student
  • Retired
  • Other

• Employment Information

• Employer
• Occupation
• Address of Employer
• City
• StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific
• Zip

• Spouse Information

• Spouse's First Name
• Last Name
• Date of Birth
  
  Date Format: MM slash DD slash YYYY
  
• Spouse's Employer
• Phone

• Insurance Information

• Same as Above
  • 
    Same as Above
• First Name of Insured
• Last Name of Insured
• Insured's Date of Birth
  
  Date Format: MM slash DD slash YYYY
  
• Relationship to Patient
• Insurance Company
• I.D. Number
• IS YOUR ILLNESS OR INJURY RELATED TO ANY OF THE FOLLOWING?
  • Employment (work related)
  • Auto Accident
• Date of Injury
  
  Date Format: MM slash DD slash YYYY
  
• HOW WERE YOU REFERRED TO OUR OFFICE?
  • Internet Search
  • By a Doctor
  • By an Attorney
  • By a Patient
  • Yellow Pages
  • Other
• Who may we thank for referring you to our office?
• Signature
• Your Name
• Date
  
  Date Format: MM slash DD slash YYYY
  
• Parent/Guardian Name (for patient under 18 years of age)

• Pain Profile

• Check if you are experience any of the following:
  • 
    Numbness
  • 
    Burning
  • 
    Stabbing
  • 
    Tingling
  • 
    Dull Ache
• Indicate where you feel numbness.
  • 
    Head
  • 
    Neck
  • 
    Mid-Back
  • 
    Lower-Back
  • 
    Other
• 
• 
• 
• Please Explain
• Rate Your Pain
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

  10 being the worst

• Are your symptoms a result of:
  • Motor Vehicle Accident
  • Work Related Accident
  • Cause Unknown
  • Other
• How often do you experience your symptoms?
  • Constantly (76-100% of the day)
  • Frequently (51-75% of the day)
  • Occasionally (26-50% of the day)
  • Intermittently (0-25% of the day)
• Indicate where you feel burning.
  • 
    Head
  • 
    Neck
  • 
    Mid-Back
  • 
    Lower-Back
  • 
    Other
• 
• 
• 
• Please Explain
• Rate Your Pain
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

  10 being the worst

• Are your symptoms a result of:
  • Motor Vehicle Accident
  • Work Related Accident
  • Cause Unknown
  • Other
• How often do you experience your symptoms?
  • Constantly (76-100% of the day)
  • Frequently (51-75% of the day)
  • Occasionally (26-50% of the day)
  • Intermittently (0-25% of the day)
• Indicate where you feel stabbing.
  • 
    Head
  • 
    Neck
  • 
    Mid-Back
  • 
    Lower-Back
  • 
    Other
• 
• 
• 
• Please Explain
• Rate Your Pain
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

  10 being the worst

• Are your symptoms a result of:
  • Motor Vehicle Accident
  • Work Related Accident
  • Cause Unknown
  • Other
• How often do you experience your symptoms?
  • Constantly (76-100% of the day)
  • Frequently (51-75% of the day)
  • Occasionally (26-50% of the day)
  • Intermittently (0-25% of the day)
• Indicate where you feel tingling.
  • 
    Head
  • 
    Neck
  • 
    Mid-Back
  • 
    Lower-Back
  • 
    Other
• 
• 
• 
• Please Explain
• Rate Your Pain
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

  10 being the worst

• Are your symptoms a result of:
  • Motor Vehicle Accident
  • Work Related Accident
  • Cause Unknown
  • Other
• How often do you experience your symptoms?
  • Constantly (76-100% of the day)
  • Frequently (51-75% of the day)
  • Occasionally (26-50% of the day)
  • Intermittently (0-25% of the day)
• Indicate where you feel dull aches.
  • 
    Head
  • 
    Neck
  • 
    Mid-Back
  • 
    Lower-Back
  • 
    Other
• 
• 
• 
• Please Explain
• Rate Your Pain
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

  10 being the worst

• Are your symptoms a result of:
  • Motor Vehicle Accident
  • Work Related Accident
  • Cause Unknown
  • Other
• How often do you experience your symptoms?
  • Constantly (76-100% of the day)
  • Frequently (51-75% of the day)
  • Occasionally (26-50% of the day)
  • Intermittently (0-25% of the day)