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Pain Relief Questionnaire:

For Office Use Only   File #: ____________ Date: _____________ SS #: _____________

                                                             About You

Gender ___________________

 ________________________________________________________________________

 Last Name                                           First Name                                                   Middle Init.

Birthdate

        Month _________________  Day _______  Year __________

Marital Status _______________________________

Mailing Address ____________________________________________

City ___________________________    State ______    Zip __________

Home Phone _____________________    Work Phone _____________________

E-Mail Address ________________________________________

Occupation _________________________________________________________

Employer ___________________________________________________________

Referred By __________________________________

                                              Insurance Info

Company Name _____________________________________________________

Address ____________________________________________________

Phone # __________________    Group # (  Plan, Local or Policy #) _______________

Insured's Name____________________________   Insured's SS No. ______________

Relation ______________________        Date Of Birth ______/______/______

Insured's Employer _________________________________________

---Please inform us of a 2nd or 3rd insurance source

                                            Reason For Visit

The reason for this visit is a result of (Please Circle):

        Work        Sports        Auto        Trauma        Chronic

(Explain what happened) __________________________________________________

_______________________________________________________________________

Please describe the pain and its location ____________________________________

_______________________________________________________________________

When did the condition begin? ______/______/_______

Is the condition getting worse?  [ ] Yes    [ ] No    [ ] Constant    [ ] Comes and goes

Is this condition interfering with your (Please Circle):

        Work        Sleep        Daily Routine

If so, explain ___________________________________________________________

Have you had this or similar conditions in the past?    [ ] Yes    [ ] No

If so, explain ___________________________________________________________

Have you been treated by a Medical Physician for this condition?    [ ] Yes    [ ] No

If so, where? __________________________________________________________

Have you ever been treated by a Chiropractor before?    [ ] Yes    [ ] No

If so, whom? _________________________________   Phone # ________________

                                     In Event of Emergency

Emergency Contact ____________________________  Relation ________________

Home Phone __________________________  Work Phone _____________________

Who is your Medical Doctor _______________________   Phone # ______________

                                     Account Information

                        Person ultimately responsible for account

Name _____________________________________   Relation __________________

Billing Address ____________________________________________________

City _______________________________    State ________    Zip _____________

SS # __________________________  D.L.# ________________________________

Work Phone ___________________________

Payment Method        [ ] Cash        [ ] Check

        ____________________________________  ___/___

        [ ] Credit Card - Enter card number above (if accepted)

________    I hereby authorize assignment of my insurance rights and benefits directly

   ^Initials       to the provider for services rendered. I fully understand I am solely

responsible for any balance not paid for by my insurance company (if offered at this office).