Appointment Information

Have you already scheduled an appointment?
Yes
No
If no, what is the best number to reach you?

 

Which office would you like to be seen at?
Sawdust/The Woodlands
Kuykendahl

Patient Data

* First Name:
* Last name:
Date:
* Email

Our email with NOT be given
to thirds parties, only used
for office communications
and promotions.

 

Mailing Address

Address
City
State
Zip Code
Telephone (home)
Telephone (work)
Telephone (cell)
Referred by
Age
Birth Date
Number of Children
Occupation
Employer
Marital status
Spouse's name
Spouse's Occupation
Spouse's Employer
Spouse's health status
Emergency contact
Telephone



Current Complaints

Nature of Injury

 
Please describe
Date of injury (if applicable)
Date symptoms appeared
Have you ever experienced this condition before?
Yes
No
If yes, when?
Have you ever been under chiropractic care?
Yes
No
If yes,approximately when was your last treatment



Insurance Information

We will try to verify your insurance coverage, based on the information provided, prior to the time of your appointment to better assist you.

Name of party responsible for payment
Do you have health insurance?
Yes
No
Name of health insurance company
Name of Policy Holder (i.e. husband, wife, parent)
Policy Holder's Date of Birth
Policy number
Group number
Insurance Company Phone Number (usually listed on the back of your card

 *If an auto accident, please provide:

Insurance company name
Contact name
Phone
Claim number
Attorney's name
Attorney's phone number

Signatures (Will be obtained when you come for your appointment)

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment.

I hereby authorize Sunrise Chiropractic Group, Inc. to release my medical information to my health insurance company, automobile insurance company, or any other insurance company providing medical coverage benefits to me for the completion of my insurance form(s). I also hereby authorize and request payment of any medical/chiropractic benefits to which I may be entitles from my insurance policy, including automobile personal injury protection, be made payable to and forwarded to Sunrise Chiropractic Group, Inc 25300 Borough Park Drive, Suite B, Spring, Texas 77380.

Patient's signature _______________________________________________

Date ____________________

Spouse's or guardian's signature __________________________________

Date ____________________


Medical History

Family medical doctor/primary care physician's name
Phone number
May we send reports or updates to your medical doctor for their files?
No
Yes
Have you been treated for any conditions in the last year?
Yes
No
If yes, please describe
Date of last physical exam
Is there a chance that you are pregnant?
Yes
No
Have you had X-rays taken withn the past 18 months?
Yes
No
If yes, where?
What medications are you taking and for what conditions (Please list dosage and amounts, etc).
What vitamins, minerals, or herbs do you currently take? (Please list for what condition, dosage, and frequency).


Have you ever:

Broken bones?
Yes
No
Briefly explained
Been hospitalized
Yes
No
Briefly explain
Had sprains/strains
Yes
No
Briefly explain
Been in an auto accident
Yes
No
Briefly explain
Been struck unconscious?
Yes
No
Briefly explain
Had surgery
Yes
No


Family History

Family members present and past medical conditions (Ex. Heart disease, Cancer, Diabetes, Arthritis, etc)

Personal History

Do you experience pain every day?
Yes
No
Do your symptoms interfere with daily life?
Yes
No
Does pain awaken you at night?
Yes
No
Are your symptoms worse during certain times of the day?
Yes
No
Do changes in weather affect your symptoms?
Yes
No
Do you wear orthotics?
Yes
No
Do you take vitamins or supplements?
Yes
No

Habits

Alcohol
Coffee
Tobacco
Drugs
Exercise
Sleep
Appetite
Soft Drinks
Water
Salty Foods
Sugary Foods
Artificial Sweetners

 

Have you ever suffered from any of the following?

Allergies
Yes
No
Anemia
Yes
No
Arteriosclerosis
Yes
No
Arthritis
Yes
No
Asthma
Yes
No
Back Pain
Yes
No
Breast Lump
Yes
No
Bronchitis
Yes
No
Cancer
Yes
No
Chest Pains
Yes
No
Cold Extremities
Yes
No
Cramps
Yes
No
Depression
Yes
No
Diabetes
Yes
No
Digestive Problems
Yes
No
Dizziness
Yes
No
Ringing in the ears
Yes
No
Excessive menstruation
Yes
No
Eye pain/visual problems
Yes
No
Fatigue
Yes
No
Frequent Urination
Yes
No
Headache
Yes
No
Hemorroids
Yes
No
High Blood Pressure
Yes
No
Hot Flashes
Yes
No
Irregular Heart Beat
Yes
No
Irregular cycle
Yes
No
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