Patient History Form Download the PDF version or fill out and submit the form below. Step 1 of 6 16% Patient InformationDate* Date Format: MM slash DD slash YYYY SS/HIC/Patient ID #*Patient Name* First Middle Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email* Sex*MaleFemaleAge*Birthdate* Date Format: MM slash DD slash YYYY Status*MarriedWidowedSingleSeparatedDivorcedPartneredMinor# of yearsOccupationPatient Employer/SchoolEmployer/School Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Employer/School PhoneSpouse's Name First Last Spouse's Birthdate Date Format: MM slash DD slash YYYY Spouse's SS#Spouse's EmployerWhom may we thank for referring you? Phone NumbersHome PhoneCell PhoneBest time and place to reach you:Emergency Contact NameEmergency Contact RelationshipEmergency Contact Home PhoneEmergency Contact Work Phone InsuranceWho is responsible for this account?Relationship to PatientInsurance Co.Group #Is patient covered by additional insurance?*YesNoSubscriber's NameBirthdate Date Format: MM slash DD slash YYYY SS#Relationship to PatientInsurance Co.Group #Assignment and ReleaseI certify that I, and/or my dependent(s), have insurance coverage withName of Insurance Company(ies)and assign directly all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named doctor may use my health care information and may disctoss such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.Signature of Patient, Parent, Guardian or Personal Representative*Please type name of Patient, Parent, Guardian or Personal RepresentativeDate Date Format: MM slash DD slash YYYY Relationship to Patient Accident InformationIs condition due to an accident?*YesNoDate Date Format: MM slash DD slash YYYY Type of AccidentAutoWorkHomeOtherTo whome have you made a report of your accident? Auto Insurance Employer Worker Comp. Other Attorney Name (if applicable) Patient ConditionReason for visitWhen did your symptoms appear?Is this condition getting progressively worse?YesNoUnknownRate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain)Please enter a number from 1 to 10.Type of Pain Sharp Burning Dull Tingling Throbbing Cramps Numbness Stiffness Aching Swelling Shooting Other How often do you have this pain?Is it constant or does it come and go?Does it interfere with your Work Sleep Daily Routine Recreation Activities or movements that are painful to perform Sitting Standing Walking Bending Lying Down Health HistoryWhat treatment have you already received for your condition? Medications Surgery Physical Therapy Chiropractic Services Other OtherName and address of other doctor(s) who have treated you for your conditionDate of Last Physical Exam Date Format: MM slash DD slash YYYY Date of Last Spinal X-Ray Date Format: MM slash DD slash YYYY Date of Last Blood Test Date Format: MM slash DD slash YYYY Date of Last Spinal Exam Date Format: MM slash DD slash YYYY Date of Last Chest X-Ray Date Format: MM slash DD slash YYYY Date of Last Urine Test Date Format: MM slash DD slash YYYY Date of Last Dental X-Ray Date Format: MM slash DD slash YYYY Date of Last MRI, CT-Scan, Bone Scan Date Format: MM slash DD slash YYYY Check the box to indicate if you have had AIDS/HIV Alcoholism Allergy Shots Anemia Anorexia Appendicitis Arthritis Asthma Bleeding Disorders Breast Lump Bronchitis Bulimia Cancer Cataracts Chemical Dependency Chicken Pox Diabetes Emphysema Epilepsy Fractures Glaucoma Goiter Gonorrhea Gout Heart Disease Hepatitis Hernia Herniated Disk Herpes High Blood Pressure High Cholesterol Kidney Disease Liver Disease Measles Migraine Headaches Miscarriage Mononucleosis Multiple Sclerosis Mumps Osteoporosis Pacemaker Parkinson's Disease Pinched Nerve Pneumonia Polio Prostate Problem Prosthesis Psychiatric Care Rheumatoid Arthritis Rheumatic Fever Scarlet Fever Sexually Transmitted Disease Stroke Suicide Attempt Thyroid Problems Tonsillitis Tumors, Growths Typhoid Fever Ulcers Vaginal Infections Whooping Cough Other OtherExerciseNoneModerateDailyHeavyWork ActivitySittingStandingLight LaborHeavy LaborHabits Smoking Alcohol Coffee/Caffeine Drinks High Stress Level Packs/DayDrinks/WeekCups/DayReasonAre you pregnant?YesNoDue Date Date Format: MM slash DD slash YYYY Injuries/Surgeries you have had including falls, head injuries, broken bones, dislocations, surgeries (include date and description)MedicationsPharmacy NamePharmacy PhoneAllergiesVitamins/Herbs/Minerals
