Date:     Face Sheet #:     Computer Id #:   

Patient Information

First Name Middle InitialM.I. Last Name Email Name of Family Physician
Street Address Apt. City State Zip
Home Phone Cell Phone Age Date of Birth Sex Marital Status Social Security Number
Nearest Relative (spouse, parent, etc) Address Relationship Phone
Emergency Contact Name Relationship Phone Referred to the Office By

Employment Information (For patient, spouse, and/or both parents)

Person Employed (copy from above) Date of Birth Job Title Social Security Number
Employer Address Phone
Person Employed Date of Birth Job Title Social Security Number
Employer Address Phone
Are you a Student? Part-time or Full-time? Name of School

Insurance Information

Name of Primary Insurance Group Number Insured Identification Number
Name of Secondary Insurance Group Number Insured Identification Number
Name of Third Insurance Group Number Insured Identification Number

Accident Information

Type of Accident (Fall, Auto, etc.) Place of Accident (Home, Work, etc.) Date of Accident
If Accident happened at work, name of Employer: Was Injury Report filed?
Is this a legal case? Name of attorney attorney Address and Phone
* * PLEASE BE ADVISED * *
THIS OFFICE DOES NOT WAIT FOR LEGAL CASES TO BE SETTLED FOR PAYMENT OF YOUR BILL - WE CONSIDER YOU RESPONSIBLE FOR YOUR BILL

Medical Information

Problem being treated for (Example: Neck, Back, Leg, Arm - Also, Which Side?)
If treated by another doctor - where? When? If treated at a hospital - where? When?
If X-rays were taken - where? When? Any allergies to medication? List here:
List Chronic Illnesses (ie: hypertension, cholesterol, etc.) If on medication - please list: Right or Left handed?