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Welcome to Kicos Chiropractic Center
Please fill this form out completely. If you have any questions,
just ask the front desk receptionist. Thank you.
1. PERSONAL INFORMATION
Today’s Date:
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File #:
Name (First/Last):
What do you prefer to be called?
Date of Birth:
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Check One: ( ) Male ( ) Female
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Social Security #:
Home Address:
City, State, Zip:
Home Phone #:
Alternate #:
Doctor or Friend who referred you to Kicos Chiropractic:
Occupation:
Work Phone #:
Employer:
How long have you worked there?
Employer’s Address:
Marital Status: ( ) Single ( ) Married ( ) Divorced ( ) Separated ( ) Widowed
Doctor’s Notes
Spouse’s Name:
2. INSURANCE INFORMATION
Insurance Company:
Phone #:
ID/Policy/Plan #:
Group #:
Claims Address:
Relation to Insured:
Insured’s DOB:
Insured’s Name:
/
/
Social Security #:
Insured’s Employer:
Please inform front desk receptionist if you have a second insurance source.
3. REASON FOR VISIT
Have you ever been treated by a Chiropractor before? ( ) Yes
( ) No
If so, please explain:
This visit is due to (please circle one or more): Work / Sports / Auto / Trauma / Chronic Pain
Explain what happened:
Describe the pain and its location:
When did the condition begin?
Is the condition getting worse? ( ) Yes ( ) No ( ) Constant ( ) Comes and Goes
Is the condition interfering with your (please circle one or more): Work / Sleep / Daily Routine
If so, please explain:
Have you been treated by a Medical Physician for this condition? ( ) Yes ( ) No
If so, when and by whom?
4. MEDICAL HISTORY
Are you taking any of the following medications?
( ) Nerve Pills
( ) Pain Killers, including Asprin
( ) Muscle Relaxants
( ) Blood Thinners
( ) Tranquilizers
( ) Other/s:
( ) Insulin
( ) Stimulants
Do you now have, or have you ever had any of the following diseases/medical conditions?
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
Heart Attack / Stroke
Congenital Heart Defect
Alcohol / Drug Abuse
HIV+ / AIDS
Frequent Neck Pain
High / Low Blood Pressure
Severe / Frequent Headaches
Fainting / Seizures / Epilepsy
Diabetes / Tuberculosis
Lower Back Problems
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
Heart Surgery / Pacemaker
Mitral Valve Prolapse
Venereal Disease
Shingles
Emphysema / Glaucoma
Psychiatric Problems
Kidney Problems
Sinus Problems
Difficulty Breathing
Artificial Bones / Joints
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
Heart Murmur
Artificial Valves
Hepatitis
Cancer
Anemia
Rheumatic Fever
Ulcers / Colitis
Asthma
Chemotherapy
Arthritis
Please list any other serious medical conditions you have or ever had:
Please list anything you are allergic to:
List previous surgeries / treatments with dates:
List any past serious accidents with dates:
Family medical information that may be relevant:
Do you smoke? ( ) No ( ) Yes / How much?
Are you wearing: ( ) Heel Lifts ( ) Sole Lifts
How Long?
( ) Inner Soles ( ) Arch Supports
What is the age of your mattress?
Women: Are you taking birth control? ( ) Yes ( ) No
Is it comfortable? ( ) Yes ( ) No
Are you pregnant? ( ) No ( ) Yes / How far along?
5. ACCOUNT INFORMATION
Name of person ultimately responsible for account:
Relation:
Billing Address:
Social Security #:
Work Phone #:
Payment Method: ( ) Cash ( ) Check ( ) Credit Card ( ) Insurance – Please give the receptionist your insurance card to copy
( ) I hereby authorize assignment of my insurance rights and benefits directly to the provider for services rendered, if offered at this
office.
▪ We invite you to ask us any questions regarding our services. The best health services are based on a friendly, mutual
understanding between the provider and the patient.
▪ Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with
the office manager. If account is not paid within ninety(90) days of the date of service and no financial arrangements have been
made, you will be responsible for legal fees, collection agency fees and any other expenses incurred in collecting your account.
▪ I am fully responsible for any expenses not paid by my insurance carrier, including all copayments and any coinsurance amounts.
▪ I authorize the provider to release any information required to process insurance claims.
▪ I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand
that it is my responsibility to inform this office of any changes in my medical and insurance status.
Signature:
Date: