New Patient Health History Form
In order to provide you the best possible care, please complete this form
and bring it to your first appointment. All information is strictly CONFIDENTIAL.
First Name Last Name Date Email*
* Your email will NOT be shared with any 3d parties, and is used for occasional office announcements and promotions.
Address City State Zip
Telephone (Work) (home) Referred By
Age Birth Date Social Security # Number of Children
Marital Status Spouse's Name Spouse's Occupation
Spouse's Employer Spouse's Health Status
Emergency Contact Phone
Nature of Injury:
Date of Injury Date symptoms appeared
Have you ever had same condition? If yes, when?
List of other practitioners seen for this injury/condition
Have you ever been under chiropractic care?
If yes, please describe
Name of party responsible for payment Phone
Do you have health insurance? Name of company
* If an auto accident, please provide:
Insurance Company Name Contact Person
Phone: Claim #
Name of the insured ________________________________________________________________________
I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier
and myself. I understand and agree that all services rendered to me and charged are my personal
responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for
professional services rendered to me will be immediately due and payable.
Patient’s signature _______________________________________________ Date ____________________
Spouse’s or guardian’s signature __________________________________ Date ____________________
© Copyright 2005 ChiroMatrix