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About
- Our Team
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Contact

New Patient Paperwork

About
- Our Team
Services
Conditions
Blog
Areas We Serve
Symptom Quiz
Contact

About
- Our Team
Services
Conditions
Blog
Areas We Serve
Symptom Quiz
Contact

New Patient Paperwork

New Patient Paperwork

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Date*
Name*
Social Security #*
Phone*
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Fax #
Cell Phone
Age*
Birth Date*
Race
Marital Status
- Married
- Single
- Widowed
- Divorced
Occupation
Employer
Employer's Address
Street Address Address Line 2 City State ZIP Code
Spouse
Occupation
Employer
Emergency Contact
Relation
Phone
How were you referred to our office?*
Family Medical Doctor*
When doctors work together it benefits you. May we have your permission to update your medical doctor regarding your care at this office?*
- Yes
- No
Accident Information
Is this due to an accident?*
- Yes
- No
If yes what type?
- Auto Accident
- Worker's Compensation
Has it been reported?
- Yes
- No
If yes to whom?
Insurance information
Please check any and all insurance coverage that may be applicable in this case:
- Major Medical
- Medicaid
- Medicare
- Auto Accident
- Medical Savings Account & Flex Plans
- Other
Policy holder name
DOB
Name of Primary Insurance Company
Name of Secondary Insurance Company (if any)
AUTHORIZATION AND RELEASE:*
I agree.
authorize payment of insurance benefits directly to the physician / medical office. I authorize the doctor to release all information necessary to communicate with personal physicians and other healthcare providers and payors and to secure the payment of benefits. I understand that I am responsible for all costs of chiropractic care, regardless of insurance coverage. I also understand that if I suspend or terminate my schedule of care as determined by my treating doctor, any fees for professional services will be immediately due and payable.

The patient understands and agrees to allow this chiropractic office to use their Patient Health Information for the purpose of treatment, payment, healthcare operations, and coordination of care. We want you to know how your Patient Health Information is going to be used in this office and your rights concerning those records. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent.
The following person(s) have my permission to receive my personal health information:
Patient's Signature*
Date*
Guardian's Signature Authorizing Care
Date

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Patient Name*
Date*
Doctor*
HISTORY OF PRESENT AND PAST ILLNESS:
Chief Complaint: Purpose of this appointment*
Date symptoms appeared or accident happened*
Is this due to*
- Auto
- Work
Have you ever had the same or a similar condition?*
- Yes
- No
If yes, when and describe
Days lost from work*
Date of last physical examination*
Do you have a history of stroke or hypertension*
- Yes
- No
Have you had any major illnesses, injuries, falls, auto accidents or surgeries? Women, please include information about childbirth (include dates)*
Have you been treated for any health condition by a physician in the last year?*
- Yes
- No
If yes, describe
What medications or drugs are you taking?*
Do you have any allergies to any medications?*
- Yes
- No
If yes, describe
Do you have any allergies of any kind?*
- Yes
- No
If yes, describe
Do you have any Congenital Condition?*
- Yes
- No
If YES, describe
Women: Are you pregnant?
SYMPTOMS/CONDITIONS
Have you had or do you now have any of the following symptoms/conditions? Please indicate with the letter N if you have these conditions now or P if you have had these conditions previously. N = Now P = Previously
Headaches
Loss of Balance
Neck Pain
Fainting
Stiff Neck
Loss of Smell
Sleeping Problems
Loss of Taste
Back Pain
Unusual Bowel Patterns
Nervousness
Feet Cold
Tension
Hands Cold
Irritability
Arthritis
Chest Pains/Tightness
Muscle Spasms
Dizziness
Frequent Colds
Shoulder/Neck/Arm Pain
Fever
Numbness in Fingers
Sinus Problems
Numbness in Toes
Diabetes
High Blood Pressure
Indigestion Problems
Difficulty Urinating
Joint Pain/Swelling
Weakness in Extremities
Menstrual Difficulties
Fatigue
Depression
Lights Bother Eyes
Loss of Memory
Ears Ring
Buzzing in Ears
Broken Bones/Fractures
Circulation Problems
Rheumatoid Arthritis
Seizures/Epilepsy
Excessive Bleeding
Low Blood Pressure
Osteoarthritis
Osteoporosis
Pacemaker
Heart Disease
Stroke
Cancer
Ruptures
Coughing Blood
Eating Disorder
Alchoholism
Drug Addiction
HIV Positive
Gall Bladder Problems
Ulcers
SOCIAL HISTORY
Please indicate beside each activity whether you engage in it: OFTEN= “O” SOMETIMES= “S” NEVER= “N”
Vigorous Exercise
Family Pressures
Moderate Exercise
Financial Pressures
Alcohol Use
Other Mental Stresses
Drug Use
Tobacco Use
Caffeine
High Stress Activity
Other (specify)
FAMILY HISTORY
Please review the below-listed diseases and conditions and indicate those that are current health problems of the family member. Leave blank those spaces that do not apply.
- Heart Disease
- Headaches
- Cancer
- Low Back Pain
- Diabetes
- Scoliosis
- Arthritis
- Allergies/Asthma
Certify*
I certify the information provided is accurate to the best of my knowledge:
Name of Patient*
Signature of Patient/Legal Guardian*
Date*

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NEUROLOGICAL / VASCULAR QUESTIONNAIRE
Name*
Date*
FOR ANY YES ANSWER, PLEASE INCLUDE DETAILS
Do you suffer from neck pain with pain in your shoulder, arms or hands?*
- No
- Yes
COMMENT
Do you have weakness, numbness or burning in your shoulder/arms/hands?*
- No
- Yes
COMMENT
Do your hands or arms fall asleep regularly?*
- No
- Yes
COMMENT
Do you have reduced feeling/sensation or swelling in your hands or arms?*
- No
- Yes
COMMENT
Do you suffer from loss of hand grip strength?*
- No
- Yes
COMMENT
Do you suffer from back pain with pain in your buttocks, legs or feet?*
- No
- Yes
COMMENT
Do your legs or feet fall asleep regularly?*
- No
- Yes
COMMENT
Do you have reduced feeling/sensation or swelling in your legs or feet?*
- No
- Yes
COMMENT
Do you suffer from cold hands or feet?*
- No
- Yes
COMMENT
Do you have frequent falls or find that you trip over your feet while walking?*
- No
- Yes
COMMENT
Do you suffer from headaches? If yes, how often?*
- No
- Yes
COMMENT
Have you ever been diagnosed by any physician with peripheral neuropathy?*
- No
- Yes
COMMENT
Have you tried any medication for your pain such as anti-inflammatory or pain medication?*
- No
- Yes
COMMENT: If yes, what type?
Have you tried physical therapy or chiropractic treatment before?*
- No
- Yes
COMMENT: When, and for how long?
Have you had an MRI or any advanced imaging?*
- No
- Yes
COMMENT:
Have you used any splint or braces or other prescribed by an MD?*
- No
- Yes
COMMENT:
INFORMED CONSENT TO CARE*
I agree.
A patient coming to the doctor gives him/her permission and authority to care for them in accordance with appropriate test, diagnosis, and analysis. The clinical procedures performed are usually beneficial and seldom cause any problem. In rare case, underlying physical defects, deformities or pathologies may render the patient susceptible for injury. The doctor, of course, will not provide specific healthcare, if he/she is aware that such care may be contraindicated. It is the responsibility of
the patient to make it known or to learn through health care procedures from whatever he/she is suffering from: latent pathological defects, illnesses, or deformities, which would otherwise not come to the attention of the physician.

I agree to settle any claim or dispute I may against or with any of these persons or entities, whether related to the prescribed care or otherwise, will be resolved by binding arbitration under the current malpractice terms which can be obtained by written request.
Patients signature*
Date*
Chiropractic care, like all forms of health care, while offering considerable benefit may also provide some level of risk. This level of risk is most often very minimal, yet in rare cases injury has been associated with chiropractic care. The types of complications that have been reported secondary to chiropractic care include sprain/strain injuries, irritation of a disc condition, and rarely, fractures. One of the rarest complications associated with chiropractic care, occurring at a rate between one instance per one million to one per two million cervical spine (neck) adjustments may be a vertebral artery injury that could lead to stroke. Prior to receiving chiropractic care this Chiropractic office, a health history and physical examination will be completed. These procedures are performed to assess your specific condition, your overall health and, in particular, your spine health. These procedures will assist us in determining if chiropractic care is needed, or if any further examinations or studies needed. In addition, they will help us determine if there is any reason to modify your care or provide you with a referral to another health care provider. All relevant findings will be reported to you along with a care plan prior to beginning care. I understand and accept that there are risks associated with chiropractic care and give consent to the examinations that the doctor deems necessary, and to the chiropractic care including spinal adjustments, as reported following my assessment.
This notice is effective as of_________________and will expire seven years after the date on Date which you last received services from us.*
Patient Initials*
Witness*
Date*

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ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES
PATIENT NAME*
Date*
I acknowledge that i have reviewed the notice of privacy practices of Grace Medical and Chiropractic Please check one of the following:*
- I wish to receive a paper copy or privacy practices
- I do not wish to receive a paper copy or privacy practices at this time. I acknowledge that I can request a copy at any time.
Acknowledgement*
I acknowledge
I acknowledge that it is the policy of Grace Medical and Chiropractic to leave reminder messages on my phone, and to send text messages. I may make a request of alternative means of communication (within reason) in writing.
Acknowledgement*
I acknowledge.
I acknowledge that if I should have a problem or question in regard to my rights I may speak with the Privacy Officer about my concerns.
Patient Signature*
Date*

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Grace Medical and Chiropractic
13720 North Cleveland Avenue Suite B
North Fort Myers, Florida 33903

(239) 997-8100

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