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Patients
Contact Us
- Appointment Request
- Request a Call Back

(256) 890-0266

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New Patient Paperwork

New Patient Paperwork

Chiropractic Case History

Name*

Date

Email *

1. Reasons for seeking chiropractic care:

Is your problem related to an accident?

Yes No

If yes, please explain:

Type of Accident:

Date of Accident:

2. Identifying Complaints:

Primary Complaint:

Secondary Complaint:

Complaint began when and how?

Please circle the type of complaint:

dull aching sharp burning throbbing deep nagging other

if Other:

Does this pain radiate or travel (shoot) to any areas of your body? Where?

Do you have any numbness or tingling in your body? Where?

Grade intensity/severity

How frequently is the complaint present, how long does it last?

Does anything aggravate the complaint?

Does anything make the complaint better?

3. Previous interventions, treatments, medications, surgery, or care you’ve sought for your complaint:

4. Past Health History:

A. Previous illness you’ve had in your life:

B. Previous injury or trauma:

Have you ever broken any bones? Which?

C. Allergies:

D. Medications:

Medication

Reason for taking

Medication

Reason for taking

Medication

Reason for taking

E. Surgeries:

Date

Type of Surgery

Date

Type of Surgery

Date

Type of Surgery

F. Females/ Pregnancies and outcomes:

Pregnancies/ Date of Delivery

Outcome

Pregnancies/ Date of Delivery

Outcome

Pregnancies/ Date of Delivery

Outcome

What was the date of the beginning of your last menstrual period?What was the date of the beginning of your last menstrual period?What was the date of the beginning of your last menstrual period?

5. Family Health History:

Associated health problems of relatives:

Deaths in immediate family:

Cause of parents or siblings death

Age at Death

Cause of parents or siblings death

Age at Death

Cause of parents or siblings death

Age at Death

6. Social and Occupational History:

A. Level of Education:

high school some college college graduate post graduate studies

B. Job Description:

C. Work Schedule:

D. Recreational Activities:

E. Lifestyle (hobbies, level of exercise, alcohol, tobacco and drug use, diet):

I have read the above information and certify it to be true and correct to the best of my knowledge, and hereby authorize this office of Chiropractic to provide me with chiropractic care, in accordance with this state’s statuses.

Parent or Guardian Signature

Date

Please Fill Out Completely

Write N/A in any space that does not apply

Name: (First) (Middle) (Last)

Age

Date of Birth

Married or Single

Address

City

State

Zip

Home Phone

Cell Phone

Work Phone

SSN

Employer

E-Mail Address

Insurance Company

Who referred you to us?

Emergency Contact: Name:

Relationship

Phone Number

Female Patient: Are you Pregnant?

Yes No

(If you or your spouse is the insured please, leave this area blank)

Name of Insured: (First) (Middle) (Last)

Date of Birth

SSN

Insured’s Employer

Insured’s Phone Number

Spouse’s Name: (First) (Middle) (Last)

Age

Date of Birth

SSN

Employer

Employer’s Phone

Spouse’s Insurance Company

Authorization and Assignment of Benefits

Signed

Date

HIPPA Notice of Privacy Practices

Print Name

Signature

Date

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

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Location

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Kay Chiropractic

Address

6945 Hwy 72 W
Huntsville, AL 35806

Contact Information (256) 890-0266

(256) 890-0268

Hours of Operation

Monday

8:00 am - 5:00 pm

Tuesday

8:00 am - 5:00 pm

Wednesday

8:00 am - 5:00 pm

Thursday

8:00 am - 5:00 pm

Friday

8:00 pm - 12:00 pm

Saturday

Closed

Sunday

Closed

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