Download If patient is under the age of 18 and needs to be seen without a

First Name __________________________ Middle Initial ____ Last Name __________________________ Date __________
Nickname ________________________ Age ________ Date of Birth ___________________ SS # ______________________
Home # __________________________ Work # _______________________ Cell # ________________________
Address ____________________________________________ City _____________________ St _____ Zip ______________
Occupation ____________________________________ Employed By _________________________________
Email (used for doctor to patient communication) _______________________________________________________________
Married ___ Single ___ Divorced ___ Widowed ___ Emergency Contact/# _________________________________________
Spouse Name ______________________ Sports/Activities you participate in ______________________________________
Have you had previous chiropractic care? ___ Where? _____________________________________
Have you seen someone for this condition before? ___ If so, who? _______________________________________________
Who referred you? ________________________________________ Relationship ____________________
Women – is there any possibility you could be pregnant? ___ 1st day of last cycle ___
Primary Policy Holder Name ________________________________________ Date of Birth _____________________
Phone ______________________ Relationship to Patient ___________________
Same Address as patient? ____ If not, please list _____________________________________________________________
Primary Care Doctor ______________________________________ Phone # _________________________
Pharmacy Name ____________________________ Phone # ________________________
Parent/Guardian Name _____________________________________ Relationship to Minor _____________________
Address _______________________________________________ City _________________ St _____ Zip _____________
Phone # ____________________________ Alternate Phone # ______________________________
If patient is under the age of 18 and needs to be seen without a parent/guardian, do you consent? ___
Consent/Signature of Parent/Guardian _____________________________
At our clinic, we are able to safely store patient credit card information in our database. Please include your credit card
information if you choose.
Card # _____________________________________ Expiration ___________ Name on Card _________________________
Dr. Michael Akerson DC CSCS (Chiropractic Physician) & Heather Akerson FNP-C (Family Nurse Practitioner)
16515 South 40th Street #133, Phoenix, AZ. 85048 (480)704-6133 pg. 1
Name _______________________________________ Date of Birth ________________ Todays Date _____________
Describe each problem you came into office with & the date it began: ___________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Have you ever had these problems/symptoms before? ___ If yes, explain: ________________________________________
_____________________________________________________________________________________________________
Have you had any significant trauma in the past? (auto accident, sport injury, fall, etc.) Give date of each. _______________
_____________________________________________________________________________________________________
List diagnosis & type of treatment you have had for your present problem(s): ______________________________________
_____________________________________________________________________________________________________
List operations &/or diseases you have had along with the dates of each: _________________________________________
_____________________________________________________________________________________________________
Have any of your blood relatives been affected by the following conditions? (circle each) Arthritis, Heart Disease,
High Blood Pressure, Kidney Disease, Tuberculosis, Allergies, Thyroid Disorders, Cancer, Other ________________________
Are you presently taking any medications? List name & dosage. _________________________________________________
_____________________________________________________________________________________________________
List any supplements that you are currently taking. ___________________________________________________________
_____________________________________________________________________________________________________
Have you seen (or considered seeing) a naturopathic physician or a traditional medicine physician who has been trained in
alternative medicine? ___
Do you pop your own back, neck, or any extremity? ___________What position do you sleep in at night? ___________
Rate your Pain 1 2 3 4 5 6 7 8 9 10 (1 being mild, 10 being severe)
In the diagram below, circle your areas of complaint.
Dr. Michael Akerson DC CSCS (Chiropractic Physician) & Heather Akerson FNP-C (Family Nurse Practitioner)
16515 South 40th Street #133, Phoenix, AZ. 85048 (480)704-6133 pg. 2