Advanced Health & Physical Therapy Solutions

Step 1 of 6Personal Information

Personal Information

I consent to appointment reminders and practice communications via SMS at the mobile number provided. Msg & data rates may apply. Reply STOP to unsubscribe, HELP for help. Consent is not a condition of treatment.

First Name*

Last Name*

Date of Birth*

Sex

MaleFemaleOther

Phone (Primary)*

Phone (Secondary)

Email Address*

Preferred Contact Method

PhoneTextEmail

Home Address*

City*

State*

ZIP*

Emergency Contact Name

Relationship

Emergency Contact Phone

Insurance Information

Skip this section if you're paying out of pocket — you can fill it in later.

Primary Insurance Provider

Policy / Member Number

Group Number

Policy Holder Name

Policy Holder DOB

Relationship to Patient

SelfSpouseChildOther

Secondary Insurance (if any)

Secondary Policy Number

Chief Complaint & Pain Assessment

Primary Complaint / Reason for Visit*

Pain Location(s)

How did it start?

How long have you had this?

Pain Level (0 = none, 10 = worst)

012345678910

No painWorst

Type of Pain

SharpDull / AchingBurningThrobbingShootingTingling / NumbnessStabbingPressure

What makes it WORSE?

SittingStandingWalkingBendingLiftingLying downCoughingDrivingMorningEvening

What provides RELIEF?

RestIceHeatStretchingPain medicationMassageWalkingNothing

Previous treatment for this condition (if any)

Medical History

Check all conditions you have or have had

ArthritisOsteoporosisHerniated DiscScoliosisSpinal StenosisSciaticaFibromyalgiaHeart DiseaseDiabetesHypertensionCancerStrokeEpilepsyHeadaches / MigrainesRheumatoid ArthritisCarpal TunnelAnxiety / DepressionOsteoarthritis

Previous surgeries / major injuries (with dates)

Current medications & supplements (name, dosage)

Known allergies (medications, latex, other)

Are you pregnant or nursing?

NoPregnantNursing

Lifestyle & Treatment Goals

Occupation / Job title

Hobbies / sports / activities

Exercise frequency

None1–2x / week3+ x / week

Sleep quality

PoorFairGood

Tobacco use

NeverFormerCurrent

Treatment goals — what you'd like to achieve

How did you hear about us?

GoogleFriend / FamilyDoctor referralInsuranceSocial mediaOther

Consent to Treatment & Financial Responsibility

I hereby authorize the practice to perform chiropractic examination and treatment as deemed necessary. I understand chiropractic treatment carries risk and that I have had the opportunity to ask questions and have them answered. I authorize the release of medical information necessary to process insurance claims. I am financially responsible for all charges not covered by insurance, and agree to pay any balance due upon receipt of statement. HIPAA: I acknowledge receipt of Advanced Health & Physical Therapy Solutions's Notice of Privacy Practices.

I have read and agree to the terms above.*

Patient Signature (or Guardian)*

Typing your name acts as your electronic signature (ESIGN Act).

Guardian Name (if minor) / Relationship