Confidential Information Form

Social Security Number
Address
City
State
Zip
Home Telephone Number
Work Telephone Number
Age
Birthdate (mm/dd/yyyy)
Marital Status
Number of Children
Spouse's Name
Occupation
Who may we thank for referring you?
In case of emergency contact
Emergency Phone Number
Name and address of employer
Employer Phone Number

HEALTH INFORMATION

Have you had previous Physical Therapy, Rehabilitation, or Chiropractic care?
Explain
Main Complaint
Past Medical History
How long have you had this condition?
Have you had similar conditions in the past?
Does this condition affect your work?
Does this condition affect your family or social life?
What aggravates this condition?
Other Doctors seen for this condition:	Neuorologist Orthopedist Psychologist General Practitioner Chiropractor Physical Therapist
Explain
List all current medications
What help your symptoms?
Have you had any surgery, falls or accidents?
When
Please describe
Date of last physical examination (mm/dd/yyyy)
Last menstral cycle

Do You Suffer From: Headaches Neck Pain Arm or Shoulder Pain Back Pain Hip or Leg Pain Chest Pain Abdominal Pain Sinus Trouble Heart Trouble Palpitation Poor Circulation High or Low Blood Pressure Female Problems Prostate Disorder Kidney Problems Bladder Problems Lung or Bronchial Disorder Digestive Disorder Constipation Loose Stool Diabetes Swollen Joints Insomnia Dizziness Numbness Nervousness Depression General Fatigue Morning Fatigue Anemia Poor Memory Hot Flashes

INSURANCE INFORMATION

Is this condition due to: A work related injury ?
An automobile accident ?
Are you covered by Medicare ?
Medicare Number
Do you have Major Medical Health Insurance ?
Insurance Company
Insurance Company Address

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that HEALTHQUEST/FINALLY HEALTH MEDICAL SERVICES will prepare any necessary reports and forms to assist me making collection from the insurance company and that any amount authorized to be paid directly to the above office will be credited to my account on receipt. However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will be immediately due and payable.

Enter Code
Verification Code