Confidential Patient Information
The following information is needed in order to better serve you. Please complete all
questions. If you need help, please ask the receptionist.
Today’s Date ________
Name___________________________________
Home phone_______________
Address__________________________ City__________ State_____ Zip code______
E-mail_____________________ Age____ Birthday________ Marital Status: M S D W
No. of children_____ Employer____________________ Occupation_______________
Employer address___________________ City__________ State_____ Zip code______
Office phone___________ SS #_______________ Driver License #________________
Do you have health insurance that you wish for us to file? Yes or No
Name of insurance company______________________ Id # ______________________
Are you covered by another insurance company? _______________________________
Name of spouse or parent_______________________ Birthday____________________
Spouse employed by________________ Occupation__________ Spouse SS#_________
Employer address _________________________________Years on job_____________
Office phone _____________
Describe the major complaint that brings you to our office
________________________________________________________________________
________________________________________________________________________
How did you learn of this office? ____________________________________________
Is this condition related to an accident? Yes ___ No___ Date of accident______________
Type of accident? Auto______ work/on job______ at home_____ other _____________
Have you ever been in an auto accident? Past year____ 5 years _____ over 5 years_____
I (we) agree to pay for services rendered to the above patient as the charge is incurred. I understand that health & accident insurance
policies are an arrangement between an insurance carrier and myself and that I am personally responsible for the payment of any and
all services covered or non covered. I also understand that if I suspend or terminate my care and treatment, any fees for professional
services rendered will be due and payable.
Patients signature_______________________________ Date___________
Spouse or Guardian’s signature ___________________ Date___________
Please check (x) all present symptoms:
CARDIOVASCULAR
( ) general swelling
( ) swelling in legs
( ) swelling in face
( ) swelling around eyes
( ) chest pain
( ) pounding heart beat
( ) heart jumps
( ) rapid heart beat
( ) blue or purple skin
( ) blue or purple nail beds
( ) fainting
( ) hypertension
Name: ________________________
( ) irregular muscle
( ) previous neck or head
movements
injury
( ) ringing in ears
( ) loss of memory
( ) heart attack
( ) inability to form words
( ) high blood pressure
(talk plainly)
( ) irregular heart beat
( ) periods of blindness in
( ) hardening of the arteries
one eye
( ) areas of muscle weakness ( ) blood vessel disease
( ) dizziness with nausea
(phlebitis)
( ) dizziness without nausea ( ) if you are a smoker
( ) blurred vision
( ) taking birth control
( ) fainting spells
( ) stroke
( ) diabetes
( ) pain over heart
VERTEBROASILAR
( ) cold hands and / or heart
( ) double vision
( ) areas of numbness
( ) loss of coordination
( ) arthritis of the neck
MUSCULOSKELETAL SYSTEM
HEAD
( ) unusually frequent
( ) pinched nerve in neck
( ) pain from front to back
headache
( ) neck feels out of place
( ) pain over kidney area
( ) unusually severe
( ) muscle spasms in neck
( ) muscle spasms in mid
headache
( ) grinding sounds in neck
back
( ) head feels heavy
( ) popping sounds in neck
LOW BACK
( ) vertigo
( ) limited neck
( ) low back pain
( ) light-headedness
( ) low back feels out of
( ) loss of smell
ARMS & HANDS
place
( ) loss of taste
( ) pain in upper arm
( ) muscle spasms in low
( ) loss of balance
( ) pain in forearm
back
( ) dizziness
( ) pain hands
HIPS, LEGS & FEET
SHOULDERS
( ) pain in fingers
( ) pain in buttocks
( ) pain in shoulders(R-L)
( ) sensation of pins &
( ) pain down leg
( ) pain across shoulders
needles in fingers
( ) knee pain
( ) tension in shoulders
( ) fingers go to sleep
( ) leg cramps
( ) can’t raise arms
( ) hands cold
( ) pins & needles in leg
( ) above head
( ) swollen joints in fingers
( ) numbness in legs
( ) shoulder level
( ) sore joints in fingers
( ) numbness in toes
NECK
( ) loss of grip
( ) cold feet
( ) pain in neck
MID BACK
( ) swollen ankles
( ) swelling in neck
( ) mid back pain
( ) swollen feet
( ) neck pain with
( ) sharp stabbing pain
movement
( ) dull ache
Name: _________________________
List ALL of your current health problems:
________________________________________________________________________
________________________________________________________________________
List any other doctors seen and list treatment received and results obtained:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
List ALL surgeries you have had and list dates:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
List ALL medications you are currently taking:
________________________________________________________________________
________________________________________________________________________
Have you ever been in an automobile accident? YES / NO When?
Have you ever had an industrial injury or any other injury for which you received
treatment? YES / NO When?
Please check (x) all conditions you have or have had:
( ) Aids
( ) epilepsy
( ) polio
( ) anemia
( ) hypoglycemia
( ) rheumatic fever
( ) arthritis
( ) multiple sclerosis
( ) tuberculosis
( ) cancer
( ) Parkinson’s disease
( ) venereal disease
Family History:
Age
Health Problems
Cause of Death
Mother: ________________________________________________
Father: _________________________________________________
Mother’s Mother: ________________________________________
Mother’s Father: _________________________________________
Father’s Mother: _________________________________________
Father’s Father: __________________________________________
Brothers: _______________________________________________
Sisters: _________________________________________________
Children: _______________________________________________
Donna S. Kile D.C.
510 Elza Drive
Oak Ridge, TN. 37830
(865) 482-8002
Signature on file and release of records
1. I authorize use of this form on all of my insurance submissions.
2. I authorize release of all information to all my insurance companies.
3. I understand that I am responsible for my bill regardless of my insurance status or
assumed benefits.
4. I authorize my doctor to act as my agent in helping me obtain payment from my
insurance company.
5. I authorize direct payment to my doctor.
6. I permit a copy of this authorization to be used in place of the original.
Signature_________________________________________Date________________