Online Forms

APPLICATION FOR CARE

PATIENT DEMOGRAPHICS

Marital Status:*
Please select at least one option

HISTORY of COMPLAINT

Please identify the condition(s) that brought you to this office:

On a scale of 1 to 10 with 10 being the worst pain and zero being no pain, rate your above complaints:

Primary or chief complaint is:*
Please select at least one option
Second complaint is:
Third complaint:
Fourth complaint:
When is the problem at its worst?
How long does it last?

*PLEASE MARK the areas on the Diagram with the following letters to describe your symptoms:

R = Radiating B = Burning D = Dull A = Aching N = Numbness S= Sharp/Stabbing T = Tingling
Is your problem the result of ANY type of accident?*
Please select at least one option

The majority of my patients have experienced dozens of impacts that can cause Vertebral Subluxation. By the time a child can walk they would have fallen 1,000 times. Identify all injuries that your spine has gone through throughout your entire life. This includes: Auto accidents, slips and falls, twists or strains at work, sports or recreational injuries, or injuries at home. (Please State Below).

PAST HISTORY

Have you suffered with any of this or a similar problem in the past?

If you have ever been diagnosed with any of the following conditions, please indicate with a P for in the Past, C for Currently have and N for Never have had:

For Women

Are you nursing?
Do you experience painful periods?
Are you taking birth control?
Do you have irregular cycles?

PLEASE identify ALL PAST and any CURRENT conditions you feel may be contributing to your present problem:

SOCIAL HISTORY

1. Smoking:*
Please select at least one option
How often?*
Please select at least one option
2. Alcoholic Beverage: consumption occurs:*
Please select at least one option
4. Recreational Drug use:*
Please select at least one option
5. Do you wear:*
Please select at least one option

FAMILY HISTORY

Does anyone in your family suffer with the same condition(s)?
If yes whom:
I hereby authorize payment to be made directly to Hamilton Family, for all benefits which may be payable under a healthcare plan or from any other collateral sources. I authorize utilization of this application or copies thereof for the purpose of processing claims and effecting payments, and further acknowledge that this assignment of benefits does not in anyway relieve me of payment liability and that I will remain financially responsible to Hamilton Family for any and all services I receive at this office.

What are your life goals and where do you see yourself in the next 10 to 20 years?

Thank you for taking the time to fill out this form.