Eugene's Chiropractor Dr. David Carlstrom

Patient Paperwork

Request an Appointment: This form is extensive and designed for our office use only and to provide us as much information regarding our patients first visit. Please fill out the form to the best of your abilities and submit the form. If you have any questions, please contact us and we'll be happy to assist you.

Patient's Full Name:

Gender

Female Male

Marital Status

Single MarriedWidowedDivorced

Number of Children

Birthday

Referred By:

Address

City, State, Zip

Phone Number

Email Address

Patient's Occupation

Patient's Employer

Business Phone

Patient's Spouse

Patient's Nearest Relative

Patient's Nearest Relative Phone #

Are you Insured?Yes No

If Yes, Complete The Following Information:
"Health Insurance Co." Contact Information with phone number.

Policy HolderSelf SpouseChild Other

Policy Holder Name

Drivers License Number

Policy Number

Group Number

Social Security Number **You will fill this out at the office**

This visit is the result of On Job InjuryInjury Other

Where Sustained?Auto Home Other

Date Of Injury

Nature of Injury: Please explain

Date of Last Physical Examination

What Operations Have You Had?

Serious Illnesses?

Have you lost any days of work?Yes No

If Yes, What are the Dates that you missed:

Please check the choice that most closely describes current goals for your health/Well Being.

I am only concerned about relief of a particular symptom.

I am only concerned about relief of a particular symptom, & preventing it's return.

I want optimum health and well being on every level for me.

Purpose of this appointment?

Other Doctors seen for this condition?

Have you been treated for any health condition by a Physician in the last year? Please describe:

What Medications or Drugs are you taking?

List diagnosis (s) and type of treatment (s):

Date of Accident:

Time of Accident:

Location of Accident

Type of AccidentAuto Collision On The Job Injury Other

Describe Accident

Did you report the injury to your foreman or employer? Yes No

Did He/She (They) Recommend Care At Our Office?
Yes No

If An Auto Accident, Were You The:
Driver Passenger Pedestrian Bicyclist

If an Auto Collision were you struck from
BehindRight Side Left Side Front Auto parked.

Did you car strike other (s) involved?Yes No

Did the other car strike yours?Yes No

As a result of the accident were traffic citations issued to you?

Yes No

The Driver of the other car was sited?Yes No

The Driver of your Car was sited?Yes No

List the extent of the injuries as you know them:

Did you require post hospitalization?Yes No

Check Symptoms you have noticed.

	Headache		Irritability
	Neck Pain		Chest Pain
	Sleeping Problems		Dizziness
	Nervousness		Pins & Needles in Arms
	Tension		Pins & Needles in Legs
	Numbness in Fingers		Head seems heavy
	Numbness in Toes		Shortness of Breath
	Fatigue		Depression
	Loss of Memory		Lights Bother eyes
	Ears Ring		Face Flushed
	Buzzing in Ears		Loss of Balance
	Fainting		Loss of Taste
	Loss of Smell		Diarrhea
	Feet Cold		Hands Cold
	Stomach Upset		Constipation
	Fever		Cold Sweats
	Other (symptoms not above).

My Insurance Co.

Their Insurance Co.

Company/Person responsible for injuries:

Have you been contacted by an Insurance adjuster or company representative regarding this claim? Yes No

Do you have an Attorney that has advised you in this case?
Yes No

If Yes, what is the contact information. Include Contact Name, Address and Phone Number.

Remarks and additional Information:

Certificates with you to your appointment.

Name of person responsible for payment

I understand and agree that health and accident insurance policies are an agreement between an insurance carrier and myself. Furthermore I understand that Dr. David Carlstrom DC will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to Dr. David Carlstrom DC will be credited to my account on receipt. However, I clearly understand and agree that all services rendered me are charged directly to me and that i am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will be immediately due and payable.

By checking the box below, I agree and understand the terms above.