1. Healthcare

David M. Warwick, D.C. · Warwick Chiropractic
8730 Tallon Lane NE #104 · Lacey WA 98516 · 360-951-4504 · www.drdavidwarwick.com
Welcome to our office!
Today’s Date:____/_____/________
How did you hear about us?
Family ________________
Friend ___________________
Co-Worker _________________
Doctor ________________________
Massage Therapist ____________________
Other health care provider__________________
New Leaf Hyperbarics
Drove by
Hospital
Insurance Plan
Dr. Warwick’s Website
Social Media
Other_____________
Personal Information
Title:
Dr.
Mr.
Mrs.
Ms.
Last:__________________________ First:___________________________ Middle: ____________________________
Suffix:
Jr
Sr
II
III
Birth Date: ____ /____/_______ Age:______
Marital Status:
Single
Married
Sex: Male / Female
Widowed
Divorced
SSN: ______________________
Separated
Address: ______________________________________________________________________________Apt # ______
City: __________________ State: ______ Zip: _________ Country: __________________
County: _____________
Home Phone: (_______) _______-_________ ext ______ Work Phone: (_______) _______-_________ ext ______
Cell Phone: (_______) _______-_________ ext ______
Fax #: (_______) _______-_________ ext ______
Email Address: _____________________________
Spouses Name: __________________________________
Children (Names and Ages): _________________________________________________________________________
Emergency Contact
Last:_____________________ First:__________________________Middle:_______________________________
Relationship:
Spouse
Relative
Friend
Other ______________________
Home Phone: (_______) _______-_________ ext ______ Cell Phone: (_______) _______-_________ ext ___
Work Phone: (_______) _______-_________ ext ______
Employment Information
Business Name: ____________________________________________________________________________________
Phone: (_______) _________-____________
Fax #: (_______) _________-____________
Employer’s Email Address: ___________________________
Occupation: __________________________
Job Description ______________________________________
Patient Initial’s____ Dr._____
Patient Name: ___________________________________
Date:________________
PLEASE LABEL ON THE DIAGRAM THE AREA OF DISCOMFORT
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When did this Condition BEGIN?
Has it ever occurred before?
Is the Condition:
Slip or Fall
_____/_______/_________
Yes
Auto Related
Lifting
→
No. When? ____________
Job Related
Slept Wrong
Home Injury
Unknown Cause
Other
Explain: ______________________________________________
Please check the following activities that AGGRAVATE your condition:
Bending
Sitting
Lying Down
Reaching
Coughing
Standing
Turning Head
Lifting
Walking
Other_________________________________
Sneezing
Please check the following activities that RELIEVE your condition:
Sitting
Heat
Standing
Lying Down
Walking
Chiropractic Adjustments
Ice
Other__________________
Lifestyle Information
Please rate your overall health:
Poor
What are your health objectives?
1
2
3
4
5
6
Pain free as quickly as possible
Pain free, correct my problem & obtain optimal wellness
Have you had previous chiropractic care? Y
7
8
9
10
Pain free & correct my problem
Wellness
N If yes, what was the doctor’s name?______________________
What was the date of your last visit?_______________
Females: Is there any chance you may be pregnant? Y
N
Do you smoke? Y N If yes, how many cigarettes per day? _____________________
Do you consume alcohol? Y N If yes, how many drinks per week? _________________
Are you currently taking any medications?
Y
N
If yes, please list__________________________________
How many times per week do you exercise?________________________________________________________
What activities do you enjoy?____________________________________________________________________
What are your work habits?
Sitting
Do you integrate movement into your day?
Use stairs instead of elevator Lifting
Walk during lunch
Standing
Light Labor
Heavy Labor
Check all that apply.
Take regular beaks to move around
Stretching
Sit on an exercise ball Other____________________
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Patient Name: ___________________________________
Date:________________
Patient Initial’s____ Dr._____
PAST HEALTH HISTORY – Fill out carefully as these problems can affect your overall course of care.
Childhood Illness (es): LIST all health conditions.
crohn’s/colitis
headaches
diabetes
HIV
food allergies (list below)
psoriasis
Adult Illness(es): LIST all health conditions.
alzheimers
CVA (stroke)
arthritis
diabetes (insulin dep)
asthma
diabetes (non insulin)
cancer
hypertension
cerebral palsy
liver disease
crohn’s/colitis
heart disease
CRPS (RSD)
hepatitis
scoliosis
seizure disorder
sickle cell anemia
HIV
lung disease
lupus erythema (discoid)
lupus erythema (systemic)
scoliosis
multiple sclerosis
parkinson’s disease
sickle cell anemia
spina bifida
other:
psoriasis
seizures
shingles
thyroid problems
vertigo
other:
Surgery (ies): LIST All Surgical Procedures. Write the DATE of the Procedure immediately afterward.
angioplasty
coronary artery bypass
joint replacement
pacemaker insertion
appendectomy
gall bladder
knee repair
rotator cuff
cardiac catheterization
hernia repair
laminectomy
spinal fusion
carpal tunnel repair
joint reconstruction
mastectomy
other:
Injuries
Mark or List All Injuries. Write the DATE of the Injury immediately afterward.
back injury
head injury (loss of consciousness)
motor vehicle accident
broken bones
head injury (no loss of consciousness)
soft tissue injury (mild)
disability (ies)
industrial accident
soft tissue injury (moderate)
fall (severe)
joint injury
soft tissue injury (severe)
fracture
laceration (severe)
other:
Family History:
Mark all that apply below.
alive
deceased
general family
alive
deceased
father
alive
deceased
mother
alive
deceased
paternal grandfather
alive
deceased
paternal grandmother
alive
deceased
maternal grandfather
alive
deceased
maternal grandmother
alive
deceased
son (s)
alive
deceased
daughter(s)
alive
deceased
brother(s)
alive
deceased
sister(s)
List any specific conditions past or present after has/had:
normally developed
normally developed
normally developed
normally developed
normally developed
normally developed
normally developed
normally developed
normally developed
normally developed
normally developed
no significant disease
no significant disease
no significant disease
no significant disease
no significant disease
no significant disease
no significant disease
no significant disease
no significant disease
no significant disease
no significant disease
has/had:______________________
has/had:______________________
has/had:______________________
has/had:______________________
has/had:______________________
has/had:______________________
has/had:______________________
has/had:______________________
has/had: _____________________
has/had: _____________________
has/had:______________________
Patient Initial’s____ Dr._____
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Patient Name: ___________________________________
Date:________________
Insurance Information:
Who Is Responsible For Your Bill?
Spouse
Worker’s Comp
YOU and… (mark appropriate box(es))
Auto Insurance
Medicare
Medicaid
Myself ONLY
Other (be specific):_______________
Personal Health Insurance Carrier: __________________
Health ID Card #: ____________________________
Policy Holder’s Name: _____________________________
Group #: ____________________________________
Policy Holder’s Date of Birth: ______-_____-_______
Primary Care Physician: _______________________
Workers Compensation Injury /
Auto
/ Personal Injury:
Have you filed an injury report with your employer?
Yes
No
Date:____/____/______Time: _______am/pm
Carrier: _____________________________________________
Policy # _______________________________
Carriers Phone #:
Adjuster: ______________________________
(_______) ___________-_______________
Claim #: _____________________________________________
Our office will provide insurance billing services for you as a courtesy. Your health insurance benefits are based on
a contract between you and your health insurance carrier and any benefits quoted are not a guarantee of payment.
I authorize direct payment of medical benefits, from my insurance company to Dr. David M. Warwick, Warwick
Chiropractic, or supplier for any services performed at this office. I also authorize the release of any medical or other
information necessary to process this claim. I also request payment of government benefits to the party that accepts
assignment.
It is understood that all reasonable efforts will be made to collect from my insurance company, and final
determination of payment will only be made after claims have been received and processed. I understand that any
and all amounts which are not collected from my insurance company shall become my responsibility, and I agree to
pay those charges within 30 days. I further agree that any insurance reimbursement check that I receive directly from
the insurance company (usually if Dr. Warwick is out of network), shall be transferred to Dr. David Warwick in full
within 10 days of my receipt of the check. If I owe a deductible or co-pay for my treatment, I agree that I shall make
all reasonable efforts to pay at time of service unless otherwise agreed upon. I understand that it is my responsibility
to pay any deductible amount, copays, coinsurance, and / or any other balances that are not covered by my contract
or paid by my insurance carrier.
I understand that motor vehicle accidents and workers compensation cases with outstanding balances will be
charged 12% interest fee annually. I also understand I am responsible for lien fees associated with filing medical
liens with the court.
I acknowledge that I have received the practice’s Notice of Privacy Practices for protected health information.
Patient’s Signature: _________________________________________________
Date: ________________
DOCTOR NOTES:
HEIGHT______ WEIGHT_______ BMI______BLOOD PRESSURE______ /______mm/Hg PULSE ______BPM BALANCE TEST(S) ______ / ______ EYES OPEN / EYES CLOSED / LEG RAISED – LT /RT /ARM(S)
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