Total Wellness Center
Patient Information Form

 

Date:
SS/HIC/Patient ID #:
Patient Name:
Nick Name:
Street Address:
City, State, Zip:
Email Address:
Whom may we thank for this referral?:
Sex:
Birthdate (including Year):
Age Today:
Marital Status:
Spouse's Name:
Spouse's SS#:
Spouse's Employer:
Home Phone:
Cell Phone:
Occupation:
Patient Employer/School:
Employer/School Address, City, State, Zip:
Have you ever been in this office before:
Yes
No
If YES, when?
Have you ever seen a Chiropractor?
Yes
No
If YES, when?
Emergency Contact:
Relationship:
Emergency Phone:
Person Responsible for Account:
Relationship to Patient:
Insurance Company:
Group #:
Additional Insurance:
Subscriber's Name:
Birthdate:
SS#:
Relationship to Patient:
Insurance Company:
Additional Insurance Group #:

 

I certify that I, and/or my dependent(s), have insurance coverage with the above Named Insurance Company, and assign directly to Dr. Geersen all insurance benefits, if any, otherwise payable to 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.

Dr Geersen may use my health care information and may disclose such information to the above named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benfits 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.

Yes
Electronic Signature of Responsible Party:
Date:
Relationship to Patient:
Reason for visit:
When did the symptoms appear:
Is the condition getting progressivly worse?
Yes
No
Only when I do certain activities
Is this condition due to an accident?
Yes
No
Date of the accident:
Type of accident:
To whom have you reported your accident:

Attorney Name (if applicable):

 

       
Head:
       
Nose:
       
Ears:
     
Mouth:
       
Neck:
 
Shoulders:
Hands/Wrists:
     
Chest:
   
Abdomen:
         
Hips:
       
Knees:
Feet:

 

 
How often do you have pain?
Does it interfere with your:
Work
Sleep
Daily Routine
Activities or movements that are painful to perform:
Work
Standing
Walking
Bending
Laying Down
Other
Check all that apply, Do you have:
The Same Condition as the Past
Severe Headaches
Pain with Sneezing or Coughing
Please check the box to indicate if you have had any of the following:
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 Cholesterol
Kidney Disease
Liver Disease
Measles
Migraine Headaches
Miscarriage
Mononucleosis
Multiple Sclerosis
Mumps
Osteoporosis
Pacemaker
Parkinson's Disease
Pinched Nerve
Pheumonia
Polio
Prostate Problem
Prosthesis
Psychiatric Care
Rheumatoid Arthritis
Rheumatic Fever
Scarlet Fever
Stroke
Suicide Attempt
Thyroid Problems
Tonsilitis
Tumors, Growths
Typhoid Fever
Ulcers
Vaginal Infections
Venereal Disease
Whooping Cough
Other
Exercise:
Work Activity:

These Questions are Vital for the Surface EMG Scan that will be performed:
Do you smoke? If so, how many packs a day?
Do you consume alcohol? If so, how many drinks per week?
Do you drink coffee or caffeine? If so how many cups per day?
Do you have a lot of stress? Reason:
Are you pregnant? If so due date:
Falling injuries you have had and Date(s):
Head injuries and Date(s):
Broken Bones and Date(s):
Surguries and Date(s):
Please list all Medications currently taking:
Please list any allergies:
Please list Vitamins/Herbs/Minerals currently taking:

 


Please Check This Box to Signify That You Have Read and Understood Our
Notice Of Privacy Practices
Yes
    

 

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

 


Home  -   About Us  -   Clinic  -   FAQs  -   Patients First Visit  -   Insurance  -   Activator Technique
Children  -   Women  -   Acupuncture  -   Nutrition  -   Nervous System  -   Cranial Massage  -   Classes
Laser Info   -   Contact Us