online forms

Constantin Chiropractic Clinic offers our patient form(s) online so they can be completed in the convenience of your own home or office.
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  • If you do not already have AdobeReader® installed on your computer, Click Here to download.

  • Download the necessary form(s), print it out and fill in the required information.

  • Fax us your printed and completed form(s) or bring it with you to your appointment.
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New Patient Health History Form

In order to provide you the best possible care, please complete this form
and bring it to your first appointment. All information is strictly CONFIDENTIAL.

Personal Data

First Name

Last Name

Date

Email


​​​​​​​* Your email will NOT be shared with any 3rd parties and is used for occasional office announcements and promotions.

Mailing Address

Address

City

State

Zip

Telephone

Home

Referred By

Age

Birth Date

Social Security #

Number of Children

Occupation:

Employer:

Marital Status:

Spouse's Name

Spouse's Occupation

Spouse's Employer

Spouse's Health Status

Emergency Contact

Phone

Current Complaints

Nature of Injury

Please describe

Date of Injury

Date Symptoms Appeared

Have you ever had same condition?


If Yes, when?

List of other practitioners seen for this injury/condition

Have you ever been under chiropractic care?

If yes, please describe

Insurance Information

Name of party responsible for payment

Phone

Do you have health insurance?

Name of company

* If an auto accident, please provide:

Insurance Company Name

Contact Person

Phone

Claim #

Signatures

Name of the insured


I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Patient’s signature

Date

Spouse’s or guardian’s signature

Date

Medical History

Have you been treated for any conditions in the last year?

If yes, please describe

Date of last physical exam

Is there a chance that you are pregnant?

Have you had X-rays taken?

If Yes, where?


What medications are you taking and for what conditions (Please list dosage and amounts, etc)l


What vitamins, minerals, or herbs do you currently take? (Please list for what conditions, dosage, and frequency).

Have You Ever

Broken bones?

Been hospitalized?

Been in an auto accident?

Had Sprains/Strains?

Been struck unconscious?

Had surgery?

Family History

Family Members - Present and past health conditions (Example: heart disease, cancer, diabetes, arthritis, etc.)

Do you experience pain every day?

Do your symptoms interfere with daily life?

Does pain wake you up at night?

Are your symptoms worse during certain times of the day?

Do changes in weather affect your symptoms?

Do you wear orthotics?

Do you take vitamin supplements?

What activities aggravate your symptoms?

Habits


​​​​​​​Alcohol


​​​​​​​Coffee


​​​​​​​Tobacco


​​​​​​​Drugs


​​​​​​​Exercise


​​​​​​​Sleep


​​​​​​​Appetite


​​​​​​​Soft Drinks


​​​​​​​Water


​​​​​​​Salty Foods


​​​​​​​Sugary Foods


​​​​​​​Artificial Sweeteners

Have you ever suffered from:

rats3898 none 8:30 AM TO 6:00 PM 8:30 AM TO 6:00 PM 8:30 AM TO 6:00 PM 8:30 AM TO 6:00 PM 8:30 AM TO 6:00 PM 8:30 AM TO 12:00 PM Closed chiropractor # # # https://www.google.com/maps/place/Constantin+Chiropractic+Clinic/@48.8463384,-122.5909382,15z/data=!4m5!3m4!1s0x0:0xc5c6e25d8d7a4635!8m2!3d48.8463384!4d-122.5909382