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Unformatted text preview: COLLEGE OF CHIROPRACTIC CLINICS Patient General Information Questionnaire Disponible en español. Form: RPF-2000 Version 3.3 Revised Oct 05, 2005 TG/se Page 1 of 4 © 2005 Life University College of Chiropractic Welcome to the Life University College of Chiropractic public, teaching clinics; where your general health screening and chiropractic care is provided by student interns under the direction of skilled licensed Doctors of Chiropractic. We truly hope you enjoy your experience here and welcome your suggestions for improvement. Prefers to be called: Age: Birthdate: ¡ M ¡ F Please complete this form and then return to the receptionist. - Please PRINT - Today’s Date: SSN: File # Last Name: First: M.I: Student Intern: # Primary Clinician: Is your visit to our clinic today for care resulting from an auto accident or workers compensation injury? ¡ Yes ¡ No Are you currently in litigation due to any health related problems? ¡ Yes ¡ No If your answer to either of the questions above is “Yes”, please see the receptionist before continuing. Home Address: City: State: Zip Code: Phones: Home: Work: Mobile: Race (optional): E-mail: Occupation: Employer: Work Address: City: State: Zip Code: Marital Status: ¡ Single ¡ Married ¡ Divorced ¡ Widowed Spouse’s Name: Number of Children: Ages: Spouse’s Employer: Phone: Spouse’s Work Address: City: State: Zip Code: Emergency Contact Person: Phone: Have you received chiropractic care in the past? ¡ Yes ¡ No When? If yes, please give name of the Chiropractor: Please describe the reason for previous care: Name of your Medical Doctor: List the name of your health insurance company: My insurance policy number is: Patient General Information Questionnaire Page 2 Form: RPF-2000 Version 3.2 Revised Oct 04, 2005 TG/se Page 2 of 4 © 2005 Life University College of Chiropractic Reason(s) for seeking chiropractic care starting with the most severe: Chief Complaint Approximate Date Started 1. 2. 3. Please answer the following to the best of your ability: In general, would you say your health is (check one): ¡ Excellent ¡ Very good ¡ Good ¡ Fair ¡ Poor Compared to one year ago, how would you rate your general health now? ¡ Much better now ¡ Somewhat worse now ¡ About the same ¡ Somewhat better now ¡ Much worse now As a child: Do you know if your birth was a difficult one? ¡ Yes ¡ No ¡ Do not know Did you have any accidents, falls, traumas, or injuries? ¡ Yes ¡ No If yes, please explain: ___________________________________________________________________...
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This note was uploaded on 11/22/2011 for the course CLIN 2504 taught by Professor Lescane during the Winter '11 term at Life Chiropractic College West.
- Winter '11