Personal Information

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THE BODY WORKS CLINIC Dr. Fiona Demel D.C. 507-263-2393

Personal Information Name: (first, middle, last) Gender:

M

F

Marital status:

Date of Birth:

Married

Single Divorced

Widowed/er

# of Children living with you:

Home Address: City, State Zip: Home Phone#:

Cell#:

Work#: Ext: Email: (used only for messages, rescheduling appointments or clinical information, we do not share email addresses) Emergency Contact:

Phone#:

Relationship to you: Employment Status:

employed full time

employed part time

student retired full-time homemaker

Occupation:

Employer:

Primary Physician:

Primary Clinic:

not currently working

TREATMENT OF MINOR CHILD I am the parent/legal guardian of the above patient and I authorize evaluation and treatment. Print Name:

Signature:

Please indicate the following in regards to appointment reminders. OK to call and leave message at: Home phone: Work phone: Cell phone: Leave message with household members: Send text reminders: Who is your cell phone provider? Ok to email billing statement:

Y N Y N Y N Y N Y N ______________ Y N

HEALTH INFORMATION

Please list the reason(s) for your appointment today:

What previous treatments and tests have you had? Consulted with family physician (name): Consulted with specialist (name): X-rays: MRI: Other test(s): Physical Therapy: Acupuncture: Other chiropractor: Massage Therapy: Strength/exercise program:

□ □ □ □ □ □ □ □

Please list any prior surgeries and/or hospitalizations:

What other health problems are you currently experiencing?

Name: What medications and supplements are you currently taking? (Attach a separate sheet if necessary) Medication/Supplement

Allergies?

Yes

or

No

Strength

Frequency

Height:

Medicine:

Weight:

Medicine:

Blood Pressure:

Medicine: Medicine: Food: Environmental:

Smoking Status (age 13 and over) Please circle one:

Current every day smoker

Former smoker

Current some day smoker

Never smoked

Patient Signature: or

Date:

Parent/Guardian Signature:

Date: