introduction patient case history

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INTRODUCTION PATIENT CASE HISTORY Date:__________________________

Patient No.:___________________

Name:________________________________________________________________________ (LAST, FIRST, M.I.) Address:______________________________________ City:_____________ Zip:__________ SSN: _______________________________________

DOB: __________________________

Mobile Phone:_________________________________ Mobile Carrier:___________________ Permission to contact via text? YES / NO Home Phone: ___________________________ Work Phone:___________________________ Email Address: __________________________ Permission to contact via E-Mail? YES / NO Married_____________ Single_____________ Other_____________ Occupation: _________________________________ Employer: _________________________ Insurance Company: ____________________________________________________________ Primary Insurance Holder’s Name and DOB:_________________________________________ Previous Chiropractic Care?: YES / NO Physician’s Name:_____________________________ Major complaint(s): ___________________________________________________________ Date of initial complaint:________________ How complaint occurred? ___________________ Recent accidents? YES / NO Date? Type of accident: _________________________________ Recent surgeries? YES / NO Date? Type of surgery: __________________________________ Allergies RX: __________________________ Allergies: _______________________________ Medications: ___________________________________________________________________ Primary Care Physician: _________________________________________________________ Whom may we thank you for referring you? __________________________________________ What ad source brought you here? __________________________________________________

It is usual and customary to pay for services as rendered unless otherwise arranged Christ Chirporactic Wellness Center 8010 East 106th Street, Suite 103 Tulsa, Oklahoma 74133 Telephone: 918-970-2900 Facsimile: 918-970-2909