Online Form

SECTION A: Patient Demographics

First Name: Last Name: Middle Initial:

Gender:   Male    Female

Date of Birth: Social Security:

Address: Apt:

City: State: FL Other Zip Code:

Home Phone: Work Phone: Cell Phone:

E-Mail:

Preferred Method of Contact:   Home   Work   Cell

Employer: Spouse's Name:

SECTION B: Insurance Information

Insurance Company:

Policy ID#:

Group ID#:

Insured Name: (If Other Than Patient)

Insured DOB: (If Other Than Patient)

SECTION C: Present Problem

Pleas list, in order of severity, all areas of pain and/or discomfort:

Chief Complaint:

Other Complaint:

Other Complaint:

Other Complaint:

When Did Your Main Complaint Begin:

What Do You Think Brought This On?:

Frequency of Pain: Constant (present at least every day) Frequent (present most of the week) Intermittent (comes and goes) Occasional (present every once in a while)

Describe the Type of Pain: Sharp Stabbing Burning Electrical Dull Achy Tension Stiff (Please Select All That Apply)

Who Is Your Family Physician: Telephone #:

Last Date Seen: Reason for that Visit:

Please list EACH and EVERY medication you are currently taking and the reason for each medication listed:

SECTION D: Past Medical History

Previous Injuries / Accidents

1. Type Date

Explain

2. Type Date

Explain

3. Type Date

Explain

Previous Surgery / Serious Illness

1. Type Date

Explain

2. Type Date

Explain

3. Type Date

Explain

Previous X-RAY / MRI / CT /

1. Type Date

Explain

2. Type Date

Explain

SECTION E: Social History

Occupation:

Do You Smoke:  Yes   No

Do You Drink:    Yes    No

How old is your mattress: years            Is it comfortable:   Yes     No

Do you wear a heel lift:  Yes    No

Do you use a cervical pillow:   Yes    No

FEMALES:   Are You Pregnant: Yes    No         If Yes, How Many Weeks:

SECTION F: Privacy Practices Receipt

I acknowledge that I have read (see below) a copy of the ACMC "Notice of Privacy Practices." Yes    No  Read Privacy Practices

SECTION G: Consent and Agreements

PLEASE READ AND INITIAL BELOW

Our office is pleased to accept your insurance assignment. We offer this service as a courtesy to our patients. It must be clearly understood that the contract is between the patient and the insurance company, the account thereby being the responsibility of the patient for any amount refused by the insurance company. I hereby authorize the payment of insurance benefits be made on my behalf to Advanced Chiropractic & Medical Centers, for any services or treatment furnished me by the physician. I authorize the release of any information pertinent to my case to any insurance company or adjuster and permit the doctor to utilize my name in any demand to the insurance company in order to properly receive compensation by benefits under this insurance policy.

I Agree          Don't Agree

Please Type Initial:

Thank you for your time. All information is kept confidential and will be reviewed during your office appointment. If there is any section you are not comfortable with filling out, please call (305) 817-1661 and an associate will be happy to help. We look forward to seeing you in person and helping you as best we can. Please hit the submit button only once. See you soon...