Fill out your health history form online

For new patients only:
Please fill out this form and then go to the Appointments section to schedule your first appointment.

Date:

First Name: MI: Last Name:

Address:

Suite/Apt #

City: State: Zip Code:

D.O.B: SS# - -

Home Phone Number: ( ) -

Work Phone Number: ( ) -

E-Mail Address:

Marital Status:

Spouse's Name:

Do yo have children? Yes No How many?

Referred by:

Employer's Address:

Suite/Apt #

City: State: Zip Code:

Occupation:

Describe your Ailment:

Are you taking any of the following medications:

Nerve pills

Pain killers (including aspirin)

Muscle relaxers

Stimulants

Blood thinners

Tranquilizers

Insulin

Other:

Do you now have or have you ever had any of the following:

Heart attack / stroke

Congenital heart defect

Alcohol / drug abuse

HIV positive / AIDS

Frequent neck pain

High / low blood pressure

Severe or frequent headaches

Fainting/seizures/epilepsy

Diabetes / tuberculosis

Lower back problems

Heart surgery / pacemaker

Mitral Valve Prolapse

Venereal disease

Shingles

Emphysema / Glaucoma

Psychiatric problems

Kidney problems

Sinus problems

Difficulty breathing

Artificial bones / joints

Heart murmur

Artificial valves

Hepatitus

Cancer

Anemia

Rheumatic Fever

Ulcers / Colitis

Asthma

Chemotherapy

Arthritis

Describe any current medical treatment including drugs taken, even though not listed above:

Contact:

Relationship to you:

Home phone # Work phone #:

Who is your medical doctor: Phone #:

Person ultimately responsibile for your account:

First Name: MI: Last Name:

Relationship to you:

Billing address:

Suite/Apt #

City: State: Zip Code:

Phone Number: ( ) - SS# - -

D.L. #:

Work Phone: ( ) -

Payment method: Cash Check Credit Card

Credit Card Type: Visa Mastercard Other

Credit Card Number:

Exp. date:

We invite you to discuss with us any questions regarding our services. The best health services are based on a friendly, mutual understanding between providor and patient.

Our policy requires payment in full for all services rendered at the time of the visit, unless other arrangements have been made with the business manager. If your account has not been paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, and any other expenses incurred in collecting your account.

By submitting this form you agree to authorize the staff to perform any services needed during diagnosis and treatment. You also hereby authorize the provider and or managed care organization to release any information required to process your insurance claims.

By submitting this form you guarantee that it was completed correctly to the best of your knowledge and that you understand that it is your responsibility to inform this office of any changes to the information you have provided.