Registration InformationFirst Name*Middle Name*Last Name*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Cell PhoneBirthday* MM DD YYYYSex*MaleFemaleMartial Status*MSDWSepEmail* Work PhoneOccupationEmployerReferred ByEmergency Contact*Emergency Phone*Spouse/Person Approved for Personal Info*Children's NamesPlease check any and all insurances you will be using Workers Compensation Private Medical Ins. Auto Accident MedicareHealth HistoryWho is your primary care physician (doctor and/or practice)Please indicate if you are currently experiencing any of the following conditions Neck Pain/Stiffness Low Back Pain/Stiffness Sciatica Arm Pain Knee Pain Headaches Dizziness Asthma Pins/Needles in Arms Pins/Needles in Legs Fatigue Sleeping Difficulties Allergies Blurred Vision Depression Nervousness Cold Swells Sudden Weight Loss/Gain Loss of Memory Jaw Problems Shortness of Breath Nausea Chest Pain Fever Fainting Bowel/Bladder ChangesPlease indicate the possible cause of your pain Auto accident Work injury Fall Lifting Bending Reaching Sleeping in poor position Coughing/sneezing Sports injury Driving Sitting Trauma OtherIndicate how severe10 (severe)98765 (moderate)4321 (minimal)and how often constant intermittent mornings evenings/night walking/activity sitting rest drivingPlease check to indicate if YOU have ever had any of the following Back surgery Neck surgery Aids/HIV Alcoholism Allergy shots Anemia Anorexia Appendicitis Asthma Bleeding disorders Breast lumps Bronchitis Bulimia Cancer Chemical dependency Diabetes Epilepsy Fractures Gout Heart disease Hepatitis Hernia Herniated disc Kidney disease Liver disease Migraines Miscarriage Multiple sclerosis Osteoporosis Pacemaker Parkinson's disease Pinched nerve Pneumonia Prostate problems Prosthesis Psychiatric care Rheumatoid arthritis Stroke Thyroid problems Tuberculosis Tumors/growths Ulcers Venereal diseaseOtherAre you currently under drug and/or medical care*YesNoIf yes, explainPlease list any medication you are currently taking (Be sure to include dosage and frequency)Please list any surgeries and/or hospitalizations you have had (type & date)Please list any allergiesPlease list any supplements you are currently taking (vitamins/herbs/minerals)Family HistoryIs there a family history of any of the following conditions Heart Disease Cancer Diabetes ArthritisOtherIndicate family member including parents, grandparents & siblings (if any of the above applies)Do you exercise?* Never Daily Weekly Walk jogWhat is your daily/weekly intake of the followingCaffeine (cups/day)Alcohol (drinks/week)Cigarettes (packs/day)I hereby authorize payment directly to this office for professional services rendered and I shall be personally responsible for any unpaid balance to the doctor. I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in the case.SignatureDate Date Format: MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.
