ETHERTON CHIROPRACTIC PATIENT INFORMATION
1103 Chestnut St. Murray, KY 42071 ● (270) 759-0030 ● Fax: (270) 767-0471
Full Name: _____________________________________________________________________
Address: _______________________________________________________________________
City: ___________________________ State: ____________ Zip: _________________________
Home Phone: ______-______-_______Work Phone: ______-______-_______ Cell Phone: ______-______-___________
Email Address: ____________________________________ Are you a student?  Yes  No  Full-Time  Part-Time
Employer or School: _____________________________________________ Occupation: __________________________
Date of Birth: ________________________ Social Security #: _______-______-_______
 Married
 Single
 Widow(er)
 Divorced
Gender: Male - Female
 Separated
If married: Spouse’s Name __________________________ Spouse’s Birth Date ________________________________
INSURANCE INFORMATION (Please allow our staff to photocopy your current health ins. card(s) & a photo I.D.)
Do you have insurance?  Yes  No Primary Ins: ______________________ Secondary Ins: _____________________
Are you the policy holder?  Yes  No If no, Name of Policy Holder ________________________________________
Date of Birth of Policy Holder: ____________ Policy Holder’s Social Security Number: ___________________________
I hereby instruct and direct any and all insurance companies, lawyers or employers liable for my health care benefits to pay by check made out and mailed to:
Etherton Chiropractic ● 1103 Chestnut St. Murray, KY 42071
Or: If my current policy prohibits direct payment to the doctor, then I hereby also instruct and direct you to make out the check to me and mail it as follows:
_
(my name)____ ● c/o Etherton Chiropractic ● 1103 Chestnut St. Murray, KY 42071
The professional or medical expense benefits allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for the professional services
rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above-mentioned
assignee, and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this insurance payment.
I hereby authorize and direct you, my insurance carrier, to pay directly to Etherton Chiropractic such sums as may be due and owing this office for services rendered me, both by reason of
accident or illness and by reason of any other bills that are due this office and withhold such sums from any disability benefits, medical payment benefits, no-fault benefits, health and
accident, Workers’ Compensation benefits, or any other insurance benefits obligated to reimburse me from any settlement, judgment or verdict on my behalf as may be necessary to
adequately protect Etherton Chiropractic. I hereby further give lien to said office against any and all insurance benefits named herein and any and all proceeds of any settlement, judgment
or verdict which may be paid to me as a result of the injuries or illness for which I have been treated for by Etherton Chiropractic. This is to act as an assignment of my rights and benefits
to the extent of the office’s services provided.
I understand that I remain personally responsible for the total amounts due the office for services rendered. I further understand and agree that this Assignment, Lien, and Authorization
does not constitute any consideration for the office to await payments, and they may demand payments from me immediately upon rendering services at their option.
A photocopy of this Assignment shall be considered as effective and valid as the original.
I also authorize the release of any information pertinent to my case to any insurance company, adjustor, or attorney involved in this case to facilitate collection under this Assignment, Lien
and Authorization.
I understand I am ultimately responsible for payment to this office. If for any reason my insurance company should pay me for services received in this office instead of paying directly to
Etherton Chiropractic, I understand that payment is for services performed here, and I must bring the payment in immediately upon receipt. Payment is required at time of service.
Patient’s Signature ___________________________________________________________ Date ___________________
How did you hear about us? ____________________________________________________________________________
ETHERTON CHIROPRACTIC PATIENT CASE HISTORY
1103 Chestnut St. Murray, KY 42071 ● (270) 759-0030 ● Fax: (270) 767-0471
What is your major complaint? _________________________________
Date problem began? _____________________
How did this problem begin (falling, lifting, etc.)? _________________________________________________________
How is your condition changing?
NOT CHANGING
Have you had this condition in the past? YES - NO
How often do you experience your symptoms?
Constantly (76-
-75% of the day)
Occasionally (26-50% of the day)
Intermittently (0-25% of the day)
Describe the nature of your symptoms:
Tightness
Stabbing
Throbbing
Sharp
Dull
Numb
Burning
Shooting
Tingling
Radiating Pain
Other: __________________________________________________________
Please rate your pain on a scale of 1 to 10 (0= no pain and 10= excruciating pain)
1
2
3
4
5
6
7
8
9
10
How do your symptoms affect your ability to perform daily activities such as working or driving?
(0= no effect and 10= no possible activities)
1
2
3
4
5
6
7
8
9
10
What activities aggravate your condition (working, exercise, etc)? _____________________________________________
What makes your pain better (ice, heat, massage, etc)? ______________________________________________________
What is your SECOND complaint? _________________________________Date problem began? __________________
How did this problem begin (falling, lifting, etc.)? _________________________________________________________
How is your condition changing?
NOT CHANGING
Have you had this condition in the past? YES - NO
How often do you experience your symptoms?
Constantly (76-
-75% of the day)
Occasionally (26-
ermittently (0-25% of the day)
Describe the nature of your symptoms:
Tightness
Stabbing
Throbbing
Sharp
Dull
Numb
Burning
Shooting
Tingling
Radiating Pain
Other: __________________________________________________________
Please rate your pain on a scale of 1 to 10 (0= no pain and 10= excruciating pain)
1
2
3
4
5
6
7
8
9
10
How do your symptoms affect your ability to perform daily activities such as working or driving?
(0= no effect and 10= no possible activities)
1
2
3
4
5
6
7
8
9
10
What activities aggravate your condition (working, exercise, etc)? _____________________________________________
What makes your pain better (ice, heat, massage, etc)? ______________________________________________________
Patient’s Signature __________________________________________________________ Date ____________________
ETHERTON CHIROPRACTIC PATIENT CASE HISTORY
1103 Chestnut St. Murray, KY 42071 ● (270) 759-0030 ● Fax: (270) 767-0471
List any Allergies:
-Ray Dye
None
List ALL Past Medical History conditions:
-Back Pain
None
Our consultation and examination may indicate that x-rays are necessary to accurately diagnose and analyze your spinal condition.
Should x-rays be necessary, we would like to confirm that you are not pregnant at this time:
Female History: Are you pregnant at this time?  Yes  No  Unsure but could be
Date of last menstrual cycle _________________  Regular  Irregular
Using birth control pills:  Yes  No
List Type of Medications you are taking:
Muscle Relaxe
None
List any Surgeries:
Back
Brain
Elbow
Other: ______________
Foot
Hip
Knee
Neck
Neurological
Shoulder
Wrist
None
Are you experiencing or do you have any of the following:
in
Have you had any auto or other accidents recently?
None of the above
When? _____________________________________
Describe: __________________________________________________________________________________________
Patient’s Signature ______________________________________________________ Date ________________________
ETHERTON CHIROPRACTIC PATIENT CASE HISTORY
1103 Chestnut St. Murray, KY 42071 ● (270) 759-0030 ● Fax: (270) 767-0471
List your Family History:
____
None of the above
- how many per day? _________________
s - how many per day? _________________
List any diagnosed conditions: (examples diabetes, cancer etc) ________________________________________________
List any cracked or broken bones & when occurred: ________________________________________________________
List any hospitalizations other than surgeries, when & what for: _______________________________________________
PLEASE MARK YOUR AREAS OF PAIN ON THE DIAGRAM BELOW
Main reason for consulting the office:
Become pain free
Explanation of my condition
Learn how to care for my condition
Reduce symptoms
Resume normal activity level
Have you ever had chiro
When? ____________ Why? __________________
Where? ___________________________________
Were XWhen was your last adjustment? _______________
Patient’s Signature __________________________________________________________ Date ____________________
ETHERTON CHIROPRACTIC CONSENT TO TREAT FORM
V. Wade Etherton, D.C.
B. Dobry Etherton, D.C.
1103 Chestnut St. Murray, KY 42071
(270) 759-0030 Fax: (270) 767-0471
Patient Name: _______________________________________________ Date ___________________
A patient coming to the doctor gives the doctor permission and authority to care for the patient in
accordance with appropriate tests, diagnosis and analysis. The clinical procedures performed are
usually beneficial and seldom cause any problem. In rare cases underlying physical defects,
deformities, or pathologies may render the patient susceptible for injury. The doctor, of course, will not
provide specific healthcare, if he/she is aware that such care may be contra-indicated. It is the
responsibility of the patient to make it known or to learn through health care procedures, from whatever
he/she is suffering from: latent pathological defects, illnesses or deformities which would otherwise not
come to the attention of the physician.
I understand that it is my responsibility to fill out my case history completely and to the
best of my knowledge, and to inform the doctor of any information that is not listed on
my case history. I also understand that it is my responsibility to inform the doctor of
changes that may occur once I have filled out that information. I authorize
V. Wade Etherton, D.C. or Bambi Dobry Etherton, D.C. to treat me.
I have read and understand the foregoing.
Patient’s Signature _____________________________________________Date___________________
Please inform the receptionist if the patient is under 18; a parent or guardian must sign a consent to treat a minor
form.
ETHERTON CHIROPRACTIC PATIENT AUTHORIZATION
V. Wade Etherton, D.C.
B. Dobry Etherton, D.C.
1103 Chestnut St. Murray, KY 42071
(270) 759-0030 Fax: (270) 767-0471
Patient Authorization for the Use and Disclosure of Protected Health Information
1. I have been presented a copy of the Etherton Chiropractic Notice of Privacy Policy.
2. I have read and fully understand the Etherton Chiropractic Notice of Privacy Policy.
3. I am aware I can contact the Privacy Officer at any time regarding any questions I may
have concerning the Etherton Chiropractic Notice of Privacy Policy.
4. I understand I can request a limitation to the disclosure of my protected health
information at any time in writing.
5. I expressly acknowledge that this authorization is voluntary.
6. I understand I may get a copy of this form by request after I sign it.
7. I understand that the information used or disclosed pursuant to this authorization, may
be subject to being disclosed again by the recipient and that this information will no
longer be protected by federal privacy regulations.
8. I hereby authorize Etherton Chiropractic to use and/or disclose my protected health
information in accordance with the procedures outlined in the Etherton Chiropractic
Notice of Privacy Policy.
Name of patient ___________________________________________
(please print)
Signature _____________________________________________________
Of patient or legal guardian if patient is under 18 or otherwise unable to sign for
himself/herself.
Date of Authorization ___________________________________________
(Authorization expires three years from date above)