CPI

 

 

CONFIDENTIAL PATIENT INFORMATION:

 

 

NAME_____________________________________________________DATE_________________

 

ADDRESS_______________________________________CITY_________________ZIP_________

 

AGE_______      DOB_________      HT______      WT______       MARITAL STATUS     M  S  W  D

 

PHONE (H)______________________(W)_____________________(CELL)___________________

 

E-MAIL________________________________EMPLOYER________________________________

 

EMERGENCY CONTACT:________________________________PHONE_____________________

 

INSURANCE COMPANY INFORMATION IN FILE____________COPY OF CARD_______________    

 

CHIEF COMPLAINT________________________________________________________________

 

HOW LONG HAS THIS EPISODE AFFECTED YOU?_____________________________________

 

How Many episodes have you had in the past? _______      Last Time? _____                                   _

 

IS THIS DUE TO: AN INJURY? ____________ ON THE JOB?____________ AUTO?____________

 

HAVE YOU LOST ANY DAYS OF WORK?______  WHEN?_________________________________

 

OTHER DOCTORS SEEN FOR THIS CONDITION?_______________________________________

 

WHAT DO YOU BELIEVE IS WRONG WITH YOU?_______________________________________

 

COMPLAINTS OTHER

THAN CHIEF COMPLAINT__________________________________________________________

 

HAVE YOU RECEIVED CHIROPRACTIC CARE PREVIOUSLY?_____________________________

 

WHAT MEDICATIONS DO YOU CURRENTLY TAKE?_____________________________________

 

                                                                                                                                                            ____

 

PLEASE LIST ALL PAST FRACTURES, SURGERIES, OR INJURIES:________________________              

 

                                                                                                                                                __________

 

IS THERE ANY OTHER MEDICAL CONDITION YOU THINK WE SHOULD KNOW ABOUT?_______

 

__________________________________________________________________________________

 

What type of treatment are you looking for?

                  _____  I’m looking for the most minimal amount of care to “patch up the symptoms” of my problem.

                  _____   I’m looking to resolve my symptoms and to “fix the cause” of my problem.

                  _____  I’m looking to take care of my problem and the go on to achieve optimal health and wellness.

 

WHO MAY WE THANK FOR YOUR REFERRAL?­­­­­­­­­­­­­­­­­­­­­­­­________________________________________

 

 

PATIENT SIGNATURE_________________________   DATE________