CPI-En | Shaw Chiropractic Group

Confidential Patient Information

This information is confidential. If we do not sincerely believe that your problem will respond favorably we will not be able to accept your case. We will refer you to disciplines we feel will help you. In order for us to understand your health problems properly, please complete this form neatly, accurately and completely. THANK YOU

Date *

SS# *

Name *

Home Phone *

Address

Street

City

State / Province / Region

Zip Code

Age *

Birth date *

Marital Status: *

# of Children *

Occupation *

Employer *

Address *

Office Phone *

Name of Spouse *

Occupation *

Employer *

Office Phone *

Other Nearest Relative *

Phone *

LIST PRESENT COMPLAINTS, INJURIES, DATE OF INJURY AND DURATION *

DOCTORS CONSULTED FOR THIS CONDITION:

Hospital Name *

Date admitted *

Date Discharged *

Treatment *

Follow-up instructions *

Name *

When consulted *

Diagnosis *

Treatment *

How long did you see the doctor? *

How Frequently *

Results *

Name *

When consulted *

Diagnosis *

Treatment *

How long did you see the doctor? *

How Frequently *

Results *

Present family doctor *

Last physical exam *

FINANCIAL INFORMATION:

Primary Insurance Company *

Policy # *

ID# *

Insured *

Secondary Insurance Company *

Policy # *

ID# *

Insured *

WHAT SURGERIES HAVE YOU HAD?

Type/When/Doctor/Results *

LIST FORMER SERIOUS ACCIDENTS AND FALLS: (AUTO, WORK, HOME, LEISURE, SPORTS, OTHER)

What/When/Symptoms/Treatment/Results *

LIST BROKEN BONES:

When/How/Doctor/Results *

LIST MEDICATIONS AND/OR DIET SUPPLEMENTS YOU TAKE:

What/Frequency/Doctors/Side Effects/Remarks

LIST ANY DISEASE OR ILLNESS WITH WHICH YOU HAVE BEEN DIAGNOSED:

(Examples: Diabetes, Heart Disease, High Blood Pressure, Stroke, Asthma, Ulcers, Cancer, Arthritis, Depression, Etc) *

WORK/LEISURE ACTIVITIES

Work Responsibilities-lifting, bending, stooping, twisting, turning, carrying, walking, standing, etc Leisure- sports and exercise type, frequency, length of time etc *

DOCTORS COMMENTS *

Phone

Confidential Patient Information

Address

DOCTORS CONSULTED FOR THIS CONDITION:

FINANCIAL INFORMATION:

WHAT SURGERIES HAVE YOU HAD?

LIST FORMER SERIOUS ACCIDENTS AND FALLS: (AUTO, WORK, HOME, LEISURE, SPORTS, OTHER)

LIST BROKEN BONES:

LIST MEDICATIONS AND/OR DIET SUPPLEMENTS YOU TAKE:

LIST ANY DISEASE OR ILLNESS WITH WHICH YOU HAVE BEEN DIAGNOSED:

WORK/LEISURE ACTIVITIES

HARTFORD

NEW BRITAIN

EAST HARTFORD

MIDDLETOWN

BLOOMFIELD

info@shawchiropractic.com

HIPAA Notice

HIPAA Notice

Videos for patients

Watch Injury TV