Patient Name:

Address:

NEW PATIENT APPLICATION

Date of Birth:

Social Security#:

Home Phone:

Occupation:

Male□　Female口

Spouse Name:

Referred By?

MaritalStatus:M S W Sep.

Spouse Birthdate:(Ib「 iIISしIr細Cc pu巾OSeS)

Purpose of this appointment or primary comp量aint:

MEDICAL HISTQ里芋Please print clca・ly and刑in as completely as possible.

Have you used any medications or treatments for this p「oblem(S):

Patient,s Primary Physician‥

Cu鴫nt drugs or medicatiollS:

PLEASE ANSW巳R CAREFULLY l‘HE LIST BELOW AS THES巴PROBLEMS CAN AF「巳CT YOUR OVERALL COURSE OF

CHIROPRACTIC CARE (Circ萱e those that apply ifyou have experienced in the last 6 months).

Pneumonia

Rheumatic Fever

Po】io

丁uberou !osis

WhoopiIlg Collgh

Anemia

Measles

Mumps

Sma= Pox

C】1ickell Pox

Diab台les

Cance「

Heart Disease

ThyrOid

Which position(S) do you sleep?

lnfluenza

P!eurisy

Ar祖霊・itis

Ep=epsy

Melltal Disorders

山m bago

Ec乙ema

霊NTAKE

Cof羊もe

丁ea

A IcohoI

C igarettes

White Sugar

Vi屯mins

HAVEYOU BEENTESTEDHIVPOS【TIVE YES / NO

Height: - Weight: _ Are yoし再appy witll yOur Curl.el-t aPPeaI.al-Ce/ab硝es・? Y / N

Doyou feel refreshed afterwakiI-g uP? Y / N 。owo-d isyou「mattress?　　Howold isyoしIr坤ow?

Doyouexerciseregularly? Y / N

How many hours do you spelld ol- an elcctrol丁ic device?　　Haveyou ever had surgery? Y / N

How many hou「s do you work? How much water do you consume in a day?

手Iaveyoueverbee虹i anautoaccideut?Y / N Date:_ Age:_ DetaiIs:

Date:　　　Age: _　Deta=s:

Were you evaluated and treated aftereach? Y / N

Haveyou had any non-VeI-icleaccidel-tSOrfa.1ls? Y / N Date‥ _ Age: _臆臆　Details:

∧ぶa函enl 〇°やl gu名証掴「ll-高-- pa高調自費「cじし叩公y lt〉「 a11 s高ce…庇「cし口、h即-臨じ咽y剛my服しl「撲れeC Ca証e「 as medcd.

Claremont Chiropractic“You deserve to have a doctor who treats you as whole person and gets results′′

CHECKANY YOU HAVE EXPERIENCED IN THE LAST 6 MONTHS

MUSCULO-SKELETAL

口　Pain Between Shoulders

口　NeckPain

口　Lower Back Pain

口　ArmPain

口JointPain

口　Walking Problem

□　D聞culty Chewing

口　General Sti珊ess

NERVOUS SYSTEM

□　Nervousness

口　Numbness

口　Dizziness

口　Forgetfulness

口　Anxiety

口　Depression

口　Stress

□　Convulsions

口　Paralysis

口　Cold/Tingling Extremities

GENERAL

GASTRO-INTESTINAL

口　Pool/ Excessive Appetite

口　Excessive Thirst

口　WeightTrouble

口　Vomiting

口　Diarrhea

ロ　Constipation

口　Hemorrhoids

口　Liver/Gall Bladder Problem

口　Abdominal Cramps

□　Gas/ BIoating

□　Heartbum

口　Black/Bloody Stool

GENITO-URINARY

□　BladderTrouble

口　Pain/Excessive Urination

□　DiscoIored Urine

C-Ⅴ-R

口　ChestPain

□　ShortBreath

□　BIood Pressure Problems

口　血egular Heartbeat

□　LungProblems

口　VaricoseVeins

□　AnkleSwe=ing

□　Strokes

EENT

口　Vision Problems

口　Dental Problems

□　SoreThroat

口　EarAches

□　StuflyNose

口　Hearing Di節culty

MALE/F E MALE

Menstrual Irregularity

Menstrual Cramps

Vaginal Pain/Infection

Breast Pain/Lumps

Prostate/Sexual Dysfunction

Other Problems

FamiIy History

The fo=owing members have a

Same Or Similar problem as I do:

口　Mother

口　Father

□　Brother

FEMALES ONLY:

When was your last period?

Are you pregnant? (Circle one)

YES NO UNSURE

PIease outline on the diagram

the area of discom宣brt.

Pain Ratingl-10: (10 being the

WOrSt yOu feel today)

How many days per week can

you commit to in order fbr yOu

to get better?

What days are you available for

treatment? M W F

口　Sister

□　Spouse

口　Child

Why Chi「opractic? Peopie go to a Chi「opracto「 fo「 a varietY Of reasons. Some go for symptomatic 「e=ef of pain discomfort (Relief Ca「e). Othe「s are

interested in having the cause ofthe p「obIem as weli as the sYmPtOm CO「「eCted and 「elieved 〈Cor「ective Ca「e〉. D「.　' Wi= weigh you「 needs and

desires when recommendingvourtreatment program. Circle theone(s) you desire most: Re=efCare / Corrective Care / Doctors Recommendation

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CLAREMONT CHIROPRACTIC

巨. M貧庇Wさ語調an

2440 W. A押oW R鳴. S蛤・ 5A

Upla吋CA 917総

(909) 6了0「獲盤5

鎚饅軸If you have mediea=n§urance,鵬are aVa鵬to heto you 「eceive you「 maXimum allowable

bene龍S. 1n orde「 to achieve崎鵬Fleed youF aSSistance and your understanding of our payment

payment fo「 services is due at the time services a「e rendered unless payment a「「angementS have

been apProVed咽vance by ou睦ff' We acc頭caSh, Chec即festerCa即ea, Discove「 and

we潮t gfadiy discuss yOur P「OPOSed treat鵬nt and answe「 any queStions 「ela軸g to you。nSuran∞・

You shouid rea腔e that:

1. Your ins脚ance js a ∞ntraC± be鵬en youI y(醐e画o締r and the jnsurance CanPany.

2. PaymentS for co-PayS and deducti。ies are due as t「eatment is 「endered. 1f you wish to know you「

benefits in advance, Please ca冊e number on the back of you「 insu「an∞ Card.

3. Our fees are generafty ∞nSidered to fa掴姐w繭e a∞ePtab]e range by mostinsurance

companies, and therefo「e are covered up to the maximum al!owan∞ determined by each ca面er誹

this is notthe case, the pa飴nt is s棚a馴Ie for悔e remaining balanee.

4. Not ali services are coVered bene紐in ali ∞ntractS. Some insuran∞ COmPanies a輔arty select

certain services they w掴ct ∞Ve串rereby ma軸g the patient ∞mPietely responsibIe for伽e charge・

we must emphasize that as medical care p「oviders, Ou「 re離onship is with yo岬Ot yOu「 insu「an∞

company. AII cha「ges are yOu「 reSPOnS輔ty from the date the services are rendered' un!ess the

∞ntract between ou「 O楕∞ and the insurance ∞mPany stateS Otherwise. We realize肘tempo「ary

軸ancial problems may a軸timely payment Of you「 account. 1f such problems do arise・ We

encou「age you to confact us p「OmP岬r assistance in the management Of your accounL

If you have any queStions about the above information or any uncerfainty rega軸g insurance

cove「貧ge; Please do not hesit貧te to ask us・ We are here to help you.

P貧tient Sig鵬tu晦

!nfomed Consent to Care

You are the decision make「 for your heath ca「e. Part of ollr rOle is to proVide you W師nformation to assist you in

藷轟繋講義萎謀議輩豊露盤謹話we may ∞nduct sonre diagn∞tic or examination proCedures串ndicated. Any eXaminations o「 teSts condu如d刷

be carefuIly perfomed’but may be un∞mfortable・

c崎raCte care Centratry i醐ives whatis knowm aS a chiropracto adj伽erfu Th純may be additional suppertive

叩Cedunes Or reCOmmendations as We肌When proViding an adjustmenL we uSe Our hands or an軸ment tO

岡持軸雅的m闘融崎軸稀前曲醍醐軸お前劇車軸随感軸曲璃珊劇画細o頓融時務湖的融船舶軸na帥融由れin嘩時刻串間醐闘

lt is impo鳴nt that you understandl aS W脚hea腫re aPProaChes・ reSu!ts are nOt guaranteect and there is no

函Se抑「e売、高th a崎S of闘離船的鵬鵬a晦SO由るksto鴎融寄g, b唖Iim軸to: muSCle spasmS’aggravating and/0「 temPOrary increase in symptomS, fack of inprovement of symptomS, burns

劉撫援恵略納鑓幽魂軸座職か珊瑚団地呼鈴埋軸虹略臨舶浄同時華andi晴耕S(陳謝b晒碑哩略細水es章軸o鳴動暗合出S画・胸記軸加応鵬S書的eis a rare but serious cond軸known as ar凋terial dis軸on that t繭weS an abrtormal change柵e脚of an

artery that may CauSe the development of a tfrombus (C書ot) whh the potentiaIto lead to a stroke. This occurs in 34

of every l OO,000 people直e伽er they are rece時g heam C剃両Patients who experien∞ this ∞ndition often,

but nct afuvays, PreSent to their me軸doctor Or細practor Wt掴ec串ain and headach& U舶厩t勘a

per∞nfage of these patents WiIl expedence a strOke. As chfropractic ca両voIve manually andIor mechanicalty

車軸粧劇画即確固坤軸や輯c輔や匝酔「タe哩卵阿曽s融e.隔発動細れ脚軸繭S飲齢d靭穣如彊細部掴め師e軸in ooe両肌e繭函○ ○ne書n

It is also irnpo励t that you understg肌d there are treatmen{ options avahabIe fdr you「 ∞nditton othe「 than

chiropractic proCedures・ Likely you have tned many of these apProaches a幅dy. These options may include朝

are no冊ted to: Se幽ministered care・ OVerthe-counter Pain reIievers’Physical measureS and resL medit違南「e

認諾霊謹譜欝騨誤認露盤霊時めa Se∞ndl have read or have had朋d to me’鵬above ∞nSeni ’appreC,a軸a陣S nO恒§S鵬to ∞融er every

pass伽∞mp脚fon to ca引have aiso融an appO南砂fo ask ques伽s abo鵬∞軸and ty §4g噂

befoM / agroe剛the cu脚{ or触re recommend細廟eceive謝apracfro ca胎aS is deemed a脚坤融血

my c肋ms如e.朝e”d鶴∞nSe融cover帥e e鵬COurse of care from a〃叩vide融的O馳for ny

present ∞棚en and for any肌re ∞ndfron㈲ for wh刷Seek c陶racfro care from鵬O触

Patient Name:

Parent or Guardian:

W帥ess Na爪e:

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Signa山鳩:

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Article 5こPevocaton: This agreement may be revoked by w碇te冊dice d執ered fo軸e hea騨腿re provider w醐30 days of

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