New Patient Information
Name and nickname: ___________________________________________________________________________
Date of Birth: _____/________/_______
Gender:
Male
Female
Address: _________________________________________________________________________
City:____________________________________State:_____Zip:____________
Phone Numbers-Home: _________________ Work: __________________ Cell: _______________
Preferred contact:
Marital Status:
Home
Married
Work
Single
Cell E-mail:____________________________________
Widowed
Divorced
Domestic Partnership
Occupation: _____________________________________________________________________
Employer: _______________________________________________________________________
Emergency Contact person: ________________________________________________________
Emergency contact phone number: __________________________________________________
How were you referred to our office: _________________________________________________
Primary Care Physician: ____________________________________________________________
INSURANCE INFORMATION
Please indicate any and all insurance coverage that may be applicable in this case.
Major Medical
Worker’s Comp
Medicare
Medicaid
Auto Accident
Name of primary insurance company _____________________________________________
AUTHORIZATION AND RELEASE: I authorize payment of insurance benefits directly to the chiropractor or chiropractic office. I authorize the doctor to release all
information necessary to communicate with personal physicians and other healthcare providers and payers and to secure the payment of benefits. I understand that
I am responsible for all costs of chiropractic care, regardless of insurance coverage. I will notify the chiropractic office of any change in my status in regards to
insurance information. I consent to the care including diagnostic procedures, examinations and treatment that the chiropractor designates and considers to be
necessary to treat my condition. The office may be reached by phone at 319-480-7492 and by fax at 888-243-0130.
The patient understands and agrees to allow this chiropractic office to use their Patient Health Information for the purpose of treatment, payment, healthcare
operations, and coordination of care. We want you to know how your Patient Health Information is going to be used in this office and your rights concerning those
records. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage
you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent. If there is anyone you do not want to receive your medical
records, please inform our office.
Patient signature: _______________________________________ Date: ____________________________
Guardian’s signature authorizing care: _________________________________Date: __________________
Larson Family Chiropractic, Laura J. Larson, DC, DICCP, 241 S. State St., Denver, IA 50622
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CURRENT CONDITION
Major complaint/symptoms:
1._______________________________________________________________________________________________
2. _______________________________________________________________________________________________
3. ______________________________________________________________________________________________
Symptoms are worse in:
morning
Symptoms:
come and go
afternoon
night
constant
Date symptoms appeared or accident happened ______________________________________________________
Describe how the injury or symptoms first occurred____________________________________________________
What positions or activities aggravate your condition:
bending
reaching
coughing
walking
lifting
lying down
What positions or activities relieve your condition:
sitting
standing
walking
lifting
turning head
lying down
sneezing
turning head
sitting
standing
bowel movement
bending
reaching
Have you been treated by a medical physician for this condition? _________________________
Have you ever had the same or a similar condition?
Yes
No
If yes, when and describe _________________________________________________________
Days lost from work ________________
Height ___________
weight ____________
Social habits Past OR present:
smoker __________ alcohol use _________
IV Drug use__________
coffee__________
tea __________
Date of last physical_____________________________
Have you ever been in any accidents, auto, fall down stairs, fall from ladder, or other significant trauma (even as a child)?
When? ______________________________________________________________________________________________
Surgeries:
Back/Joint
spinal fusion
laminectomy
disc surgery
joint reconstruction
joint replacement
rotator cuff
knee repair
carpal tunnel
Heart
angioplasty
Catheterization
artery bypass
pacemaker insertion
defibrillator
other
Female
C-section
hysterectomy
mastectomy
lumpectomy
D&C
ablation
Other
gall bladder
appendectomy
hemorrhoidectomy
tonsillectomy
cosmetic
hernia repair
Surgery dates___________________________________________________
Other surgeries not listed _________________________________________
Larson Family Chiropractic, Laura J. Larson, DC, DICCP, 241 S. State St., Denver, IA 50622
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Please list all prescription and over-the –counter medications AND supplements.
Name of Medication
Dosage
Frequency
For what condition
How long have you been taking it?
Prescribing MD
Do you have medication allergies? (Please list medication and reaction) __________________________________________
_____________________________________________________________________________________________________
Have you gained or lost weight, without trying, in the past year? ________________________________________________
Have you had a bacterial infection in the past 30 days? _______________________________________________________
FOR WOMEN
Is there any possibility you could be pregnant? ______________________________________________________________
When was your last menstrual period? ____________________________________________________________________
Do you take birth control pills? ___________________________________________________________________________
Do you have any unusual bleeding or discharge? _____________________________________________________________
Do you have any thickening in your breasts or elsewhere? _____________________________________________________
Please indicate if you have any of the following conditions:
facial pain/stiffness
neck pain/stiffness
back pain/stiffness
arm/hand pain
leg/knee pain
headaches
dizziness
Family History
pins/needles in arms
pins/needles in legs
fatigue
sleeping difficulties
asthma
allergies
blurred vision
Self
ringing in ears
depression
nervousness
tension
cold sweats
stomach problems
night pain
Father
loss of smell
loss of taste
loss of memory
jaw problems
constipation
shortness of breath
bowel/bladder problems
Mother
nausea
cold feet
chest pain
fever
fainting
problems swallowing
Sibling
High Blood Pressure
Heart Problems
Circulation Problems
Stroke (CVA or TIA)
Emphysema
Asthma
Seizures-Convulsions
Diabetes
Kidney Disease
Thyroid Disease
Cancer
Arthritis
Osteoporosis
Larson Family Chiropractic, Laura J. Larson, DC, DICCP, 241 S. State St., Denver, IA 50622
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QUADRUPLE VISUAL ANALOG SCALE
Please read carefully Please circle the number that best describes the question being asked.
NOTE: If you have more than one complaint, please answer each question for each individual complaint and indicate the score for
each complaint. Please indicate you pain level right now, average pain and pain at its best and worst.
EXAMPLE:
headache
neck
low back
No pain ___________________________________________________________________________ worst possible pain
0
1
3
4
5
7
8
10
○2
○6
○9
What is your pain right now?
no pain ___________________________________________________________________________ worst possible pain
0
1
2
3
4
5
6
7
8
9
10
What is your typical or average pain?
no pain ___________________________________________________________________________ worst possible pain
0
1
2
3
4
5
6
7
8
9
10
What is your pain level at its best? (how close to “0” is your pain at its best)
no pain ___________________________________________________________________________ worst possible pain
0
1
2
3
4
5
6
7
8
9
10
What is your pain level at its worst? (how close to “10” is your pain at its worst)
no pain ___________________________________________________________________________ worst possible pain
0
1
2
3
4
5
6
7
8
9
10
Mark the areas on this body where you feel the described sensations. Use the appropriate symbols. Mark areas of radiation.
Include all affected areas.
Numbness
---------------
Pins & Needles
ooooooooooo
Burning
xxxxxxx
Aching
******
Stabbing
////////
I verify all information provided is true and correct to the best of my ability.
Signature:___________________________________________________________Date:________________
Larson Family Chiropractic, Laura J. Larson, DC, DICCP, 241 S. State St., Denver, IA 50622
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