Shipman Chiropractic
Welcome
Our Doctors and Staff
Dr Shipman
Patients Forms
Patient Resources
Employment
Contact
Blog
Video Page
New Patient Health Record
Personal and Insurance Information
all entries with a red * are required answers
*
Indicates required field
Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Birthdate- Month
*
January
February
March
April
May
June
July
August
September
October
November
December
Birthdate- Day
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Birthdate- Year
*
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Gender
*
Male
Female
Marital Status
*
Married
Single
Divorced
Separated
Social Security #
*
Driver's License or ID #
*
Phone Number
*
Email- Please type none if you don't have email
*
Employer
*
Employer Phone Number
*
Type of Work
*
Spouse's Name (if married)
*
Spouse's Contact Number
*
Spouse's SS#
*
Spouses Employer
*
Spouse's Employer Phone
*
Names and Ages of Children
*
Referred to this office by:
*
Name of Emergency Contact
*
First
Last
Who is responsible for the bill?
*
Myself
Spouse
Worker's Comp.
Auto Insurance
Medicare
Medicaid
Personal Health Insurance
*
Card Number
*
Insured Name
*
First
Last
Insured Date of Birth
*
Emergency Contact Number
*
Current Health Conditions
Unwanted Health Condition
*
Other Dr(s) seen for condition?
*
Yes
No
If yes, who did you see?
*
Type of treatment
*
Treatment Results
*
When did this condition begin?
*
Has this condition occurred before?
*
Yes
No
Is condition related to:
*
Job Related
Auto Accident
Home Injury
Fall
Other
If accident- Date and Time
*
If other, please describe
*
If Job related, Have you reported to employer?
*
Yes
No
Medications currently taking
*
none
Nerve Pills
Pain Killer/ Muscle Relaxers
Blood Pressure Medicine
Insulin
Other
List Medications not answered above
*
Do you wear a shoe lift
*
Yes
No
List any other health conditions other than what we are seeing you for
*
Past Health History
Check all that apply
*
Major Surgery/ Operations
Appendectomy
Tonsillectomy
Gall Bladder
Hernia
Back Surgery
Broken Bones
None of the Above
If other procedures, please describe
*
Please describe any other major accidents or falls
*
Please describe hospitalizations other than above
*
Have you had previous Chiropractic Care?
*
Yes
No
If previous Chiropractic care, please list Dr's name and approximate date of last visit
*
Below is a list of diseases which may seem unrelated to the purpose of your appointment. However, these questions must be answered carefully as these problems can affect your overall course of care.
Check any of the following disease you have had
*
Pneumonia
Rheumatic Fever
Polio
Tuberculosis
Whooping Cough
Anemia
Measles
Mumps
Small Pox
Chicken Pox
Diabetes
Cancer
Heart Disease
Thyroid
Influenza
Pleurisy
Arthritis
Epilepsy
Mental Disorders
Lumbago
Eczema
NONE OF THE ABOVE
Are you a regular user of:
*
Coffee
Tea
Alcohol
Cigarettes
White Sugar
NONE OF THESE
musculo-skeletal conditions in the last 6 months
*
Low Back Pain
Pain Between Shoulders
Neck Pain
Arm Pain
Joint Pain/Stiffness
Walking Problems
Difficult Chewing/Clicking Jaw
General Stiffness
NONE OF THE ABOVE
Nervous System Disorders in the last 6 months
*
Nervous
Numbness
Paralysis
Dizziness
Forgetfulness
Confusion
Depression
Fainting
Convulsions
Cold/Tingling Extremities
Stress
NONE OF THE ABOVE
General conditions in the last 6 months
*
Fatigue
Allergies
Loss of Sleep
Fever
Headaches
NONE OF THE ABOVE
Gastro-Intestinal Conditions in the last 6 months
*
Poor/Excessive Appetite
Excessive Thirst
Frequent Nausea
Vomiting
Diarrea
Constipation
Hemorrhoids
Liver Problems
Gall Bladder Problems
Weight Trouble
Abdominal Cramps
Gas/Bloating After Meals
Heartburn
Black/Bloody Stool
Colitis
NONE OF THE ABOVE
Genito-Urinary Conditions in the last 6 months
*
Bladder Trouble
Painful/Excessive Urination
Discolored Urine
NONE OF THE ABOVE
Cardio-Vascular Conditions in the last 6 months
*
Chest Pain
Short Breath
Blood Pressure Problems
Irregular Heartbeat
Heart Problems
Lung Problems/Congestion
Varicose Veins
Ankle Swelling
Stroke
NONE OF THE ABOVE
EENT Conditions in the last 6 months
*
Vision Problems
Dental Problems
Sore Throat
Ear Aches
Hearing Difficulty
Stuffed Nose
NONE OF THE ABOVE
Male/Female Conditions in the last 6 months
*
Menstrual Irregularity
Menstrual Cramps
Vaginal Pain/Infection
Breast Pain/Lumps
Prostate/Sexual Dysfunction
Other Problems
NONE OF THE ABOVE
Females Only- When was your last period?
*
Females Only- Are you pregnant?
*
YES
NO
NOT SURE
Family History- The following family members have the same or similar problems as I do:
*
Mother
Father
Brother
Sister
Spouse
Child
None of the above
Most patients that come to our office have one or two objectives in mind concerning their health care. Some patients come for symptomatic relief of pain or discomfort (Relief Care). Others are interested in having the cause of the problem as well as the symptoms corrected and relieved (Corrective Care). Your doctor will weigh your needs and desires when recommending your treatment program.
Please check the type of care desired so that we may be guided by your wishes whenever possible.
Choose One
*
Relief Care
Corrective Care
Have Doctor select appropriate care for your condition
Final Step- agreements and E-Signature
With my typing of my name below, I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that the Doctor's Office 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 the Doctor's Office will be credited to my account on receipt. However, I clearly understand and agree that all services rendered to me are charge directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate any fees for professional services rendered to me will be immediately due and payable.
I hereby authorize the Doctor to treat my condition as he or she deems appropriate. It is understood and agreed the amount to be paid the Doctor, for X-Rays, is for examination only and the X-Ray negatives will remain the property of this office, being on file where they may be seen at any time while a patient of this office. The patient also agrees that he/she is responsible for all bills incurred at this office.
Please Provide First and Last Name for E-Signature
*
First
Last
Date
*
Consent to Treat Minor- Please sign the consent form below if the patient is under 18
Minor's Name
*
First
Last
Provide Minors Date of Birth
*
By typing my name below, I authorize Shipman Chiropractic to treat the minor listed above. I verify that I am a legal guardian or representative of the minor listed above.
E Signature
*
First
Last
Submit