Olympic Chiropractic & Physical Therapy Your Access to Quality Health Care
 
 
 
 
Olympic New Patient Form
 
 

PERSONAL HISTORY
Who is Responsible For Your Bill, You and:
If Personal Health Insurance is responsible then please provide the Name and your Health Card #.

CURRENT HEALTH CONDITION
Have other Doctors seen this Condition:
Has this condition occurred before:
Is this Condition:
Have you made a report of your accident to your employer:
What drugs are you currently taking?

PAST HEALTH HISTORY
Major Surgery/Operations:
Have you had any Previous Chiropractic Care:
If Yes, then please list the Doctor's Name & the Approximate Date of your Last Visit:
Below are a list of diseases which may seem unrelated to the purpose of your appointment.
However, these questions must be answered carefully as these problems can affect your
overall course of care.
CHECK ANY OF THE FOLLOWING DISEASES YOU HAVE HAD:
Fever
Cough
Disorders
Have you been tested HIV positive?
Do you intake any of the following:
CHECK ANY OF THE FOLLOWING YOU HAVE HAD IN THE PAST 6 MONTHS:
MUSCULO-SKELETAL CODE
NERVOUS SYSTEM CODE
GENERAL CODE
GENITO-URINARY CODE
GASTRO-INTESTINAL CODE
C-V-R CODE
FEMALES ONLY
Are you Pregnant?
EENT CODE
MALE/FEMALE CODE
OTHER PROBLEMS (list here)
FAMILY HISTORY
The following members have a
same or similar problem as I do:

DISCOMFORT DIAGRAM
Once completed, please outline on the diagram your area of discomfort.
Discomfort Diagram

TIME TO PRINT

COMPLETE LAST SECTION BY HAND
Complete this last section by hand and bring it in to our office. Thank You!
PRINT FORM CLICK HERE TO PRINT

Most patients that come to our office have one of two objectives in mind concerning their health care. Some patients come for symptomatic relief of pain or discomfort (Relief Care). Others are interested in having the cause of the problem as well as the symptoms corrected and relieved (Corrective Care). Your Doctor will weigh your needs and desires when recommending your treatment program.

Corrective Care
Corrective Care

Corrective Care differs from relief care in
that its goal is to get rid of the symptoms
or pain while correcting the cause of the
problem. Corrective care varies in length
of time, but is more lasting.

Relief Care
Relief Care

Relief Care is that care necessary to get
rid of your symptoms or pain, but not the
cause of it. It is the same as drying a floor
that was getting wet from a leak, but not
fixing the leak.

Please check the type of care desired so that we may be guided by your wishes whenever possible.
 
 Corrective Care
 
 Relief Care
 
 Check here if you want the Doctor to select
the type of care appropriate for your condition.
Patient's Signature: ________________________________ Date: ________________________
If this is an accident related injury, please fill out the Accident Form. Thank You!

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that the Doctor's Office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to the Doctor's Office will be credited to my account on receipt. However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate, any fees for professional services rendered me will be immediately due and payable.

I hereby authorize the Doctor to treat my condition as he or she deems appropriate. It is understood and agreed the amount paid the Doctor, for X-rays, is for examination only and the X-ray negatives will remain the property of this office, being on file where they may be seen at any time while a patient of this office. The patient also agrees that he/she is responsible for all bills incurred at this office.

Patient's Signature: ________________________________
Date: ________________________
Consent to Treat a Minor: ___________________________
Date: ________________________
Guardian or Spouse's
Signature of Authorizing Care: 		_______________________
Date: ________________________

DO NOT WRITE BELOW THIS LINE
DOCTOR'S AREA
ANALYSIS:
DIAGNOSIS:
Patient Accepted:
 
 YES
 
 NO
 
 REFERRED
Doctor's Signature: _________________________________ Date: ________________________
 
 
Area: Chicago
Phone: (630) 830-8600
www.OlympicChiropractic.com
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Sun Web Creations
 
 
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