to print this page                                   - Clermont Chiropractic Clinic -

 Please Print ( use only black ink )                                                                 DATE _________________ 

 
Last Name_______________________________ First___________________________    SS# __________________


Address________________________________ City _____________________________ State _____ Zip _________


Phone (        ) ___________________Gender: [ ] Male    [ ] Female    DOB _____/_____/______    Age __________


Insurance Co. ________________________________________________ Policy# ____________________________

 
Employer & Phone Number_________________________________________________________________________


Spouse’s Name __________________________________________ DOB ____/____/______  SS#_______________


Spouse’s Employer & Phone Number _________________________________________________________________

 
Referred by:____________________________________________________________________


Occupation:

[  ] Professional / Technical

[  ] Tradesman

[  ] Clerical

[  ] Homemaker

[  ] Production

[  ] Service Retail/Other

Marital Status:
[  ] Married

[  ] Widowed

[  ] Separated

[  ] Divorced

[  ] Never Married

Education Level:

[  ] less than 12 years

[  ] High School

[  ] 1-4 years college

[  ] Beyond 4 years college

[  ] Professional school

[  ] Other ____________________________

Date of last X-rays/ Imaging Studies_______________________

   

  Do you NOW have any of the following conditions (MARK ONLY IF YES)

[  ] Congestive Heart Failure? 
                                                

[  ] Chronic Lung Disease (including Bronchitis of Emphysema)? 
        
[  ] Blindness of trouble seeing, even when wearing glasses?
 

[  ] Deafness or trouble hearing?
                                 

[  ] Sugar Diabetes (Diabetes Mellitus) Type1?
 
[  ] Sugar Diabetes (Diabetes Mellitus) Type II adult onset? 

 
[  ] Asthma?            

 
[  ] Ulcer or gastrointestinal bleeding (not counting Hemorrhoids)?  
   

[  ] Arthritis or Rheumatism?                                     

[  ] Sciatica of chronic back problem?

 
[  ] Hypertension of High Blood Pressure


[  ] Angina?


[  ] Heart Attack of Myocardial Infarction?


[  ] Stroke?


[  ] Kidney disease?


[  ] Cancer?


[  ] Depression?


[  ] Other? ____________________________

_______________________________________________________________________________________________

[  ] Do you smoke? If you smoke cigarettes, how many to you smoke in an average day?

[  ] Less then pack                   [  ] to 1 pack               [  ] 1 to 2 packs                [  ] More than 2 packs

_______________________________________________________________________________________________

[  ] Do you drink?  If you drink alcohol, about how many drinks in an average day?

[  ] 1      [  ] no more than 1          [  ] 1 or 2 drinks               [  ] 3 to 5 drinks                [  ] 6 to 8 drinks

_______________________________________________________________________________________________

1. List all medications including over counter products)


_______________________________________________________________________________________________

2. List all operations / surgeries you have had:


___________________________________________________________________________________