Author: RRC

Patient

In Case of Emergency, Contact:

Name:_____________________________________________
Last First M.I.
Nick Name: ________________________________________
Address: ___________________________________________
___________________________________________________
City State Zip
Sex: M / F Age:_______ DOB:________________
Married Status Single______ Married______ Other____________
Email:_____________________________________________
Home Phone:_______________________________________
Cell:_______________________________________________
Contact Method (Pick One)
Home :________ Cell:________ Email :__________
Work:_____________________________ FT PT
Occupation:________________________________________
Employer:__________________________________________
Whom may we thank for referring you:
___________________________________________________

Insurance

Insurance Type: BCBS United Medicare Medicaid ________
Policy Holder:_______________________________________
Relationship to Holder:_______________________________
DOB :__________________
Policy Number:______________ Group Number:_________
Employment ________________________________________

W
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L
C
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Name:___________________________________________
Phone:___________________________________________
Relation:_________________________________________

Parent (If patient is a minor)

I hereby request and authorize Dr Ryle Smith DC to perform diagnostic tests, render chiropractic adjustments, and other treatments to MY MINOR CHILD____________________.
This authorization also extends to all other doctors and office staff members and is intended to include radiographic examinations at the doctor discretion.
As of this date, I have the legal right to select and authorize health care services for the minor child named above.
_______________________ ______________________
Signature Date
_______________________ ______________________
Print Name Witness
_______________________
Relationship to Patient

Doctors

Have you been to a Doctor of Chiropractic before?
Yes No
Name:___________________________________________
Clinic Doctor
Last date of visit:__________________________________
Family Medical Doctor:____________________________

Accident Information

Financial Policy

We accept the following forms of payment: cash, checks, debt/credit cards.
Full payment for your responsible portion of services is expected at the time of your visit.
Please feel free to ask any financial questions you may have.
All no-shows appointments will be assessed a $30 cash fee at your next visit.
I have read and understand the Financial Policy of Red Rock Chiropractic and I authorize them to submit insurance claims on my behalf (if applicable). I also hereby instruct and direct the payment of all professional expense benefits allowable and otherwise payable to me under my current policy to Red Rock Chiropractic as payment for services rendered. I have agreed to pay, in a current manner, any balance of said service charges over and above insurance payments. I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in my case. I authorize the use of this signature on all insurance submissions.

Is this condition due to an accident? YES NO
Date of Accident:_________ Type:___________
To Whom have you made a report of your accident? (Circle One) Auto Employer Other
Insurance Name:__________________________________
Claim Number:___________________________________
Contact Name:____________________________________

Signature

I understand that the information I have given today is correct to the best of my knowledge. I also understand this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes. I authorize the Doctor and staff to perform any necessary service that I may need during diagnosis and treatment with m informed consent.
_________________________________________
Responsible Party Signature

Patient History (Please include dates)

Accidents:_______________________________________________________________________________________
Surgeries:________________________________________________________________________________________
Medications (Including Dosages): Check if no medications are currently taken:___________
1)__________________________________________ 2)____________________________________________
3)__________________________________________ 4)____________________________________________
5)__________________________________________ 6)____________________________________________
7)__________________________________________ 8)____________________________________________
List current known allergies that you have to any medications: Check if no allergies are known:___________
1)___________________________________________ 2)____________________________________________
3)___________________________________________ 4)____________________________________________
Has any Doctor Diagnosed you with Hypertension presently? YES______ NO______ IF yes, what type_________
Has any Doctor Diagnosed you with Diabetes presently? YES______ NO______ IF yes Type I or Type II If yes to Diabetes, was your blood work test for Hemoglobing A1c > 9.0 % YES_______ NO______
Has any Doctor Diagnosed you with any type of significant health syndrome presently? YES_____ NO______
IF yes, What kind?__________________________________________________________________________
Have you had an X-ray or CT scan or MRI of your LOW BACK SPINE within the past 28 days? YES___ NO___
Hospitalizations:___________________________________________________________________________________
Are you Pregnant? YES NO Week Number:__________ LMP:__________ Nursing?: YES NO

Present Condition

Present Condition:________________________________________________________________________________
Where exactly is the problem?_______________________________________________________________________
When did the problem Begin?_______________________________________________________________________
Have you experienced this before? YES NO When?_______________ Treatment provided?__________________
Type of injury?_______________________ How did you injure yourself?__________________________________
Describe the pain___________________________________ Is it getting Worse? YES NO
Constant or Comes and Goes How often do you have this pain_______________
Rate the Pain 1 2 3 4 5 6 7 8 9 10 SEVERE
Please mark on the human figure where your pain is located.
Type of pain:
Sharp Dull Throbbing Numbness
Aching Shooting Burning Tingling
Cramping Swelling Other________________
Does it interfere with your:
Work Sleep Daily Routine Recreation
Activities of movements that are painful to perform:
Sitting Standing Walking Bending Lying Lifting
Twisting Coughing Sneezing Sleeping Moving Breathing
Check all symptoms that you are experiencing or have experienced even if
they seem unrelated to your condition:
Headache Nervousness Fainting Menstrual pain Back pain
Dizziness Tension Cold Hands Hot flashes Menstrual irregularity
Fatigue Loss of smell Heartburn Numbness in legs Stiff neck