Patient Registration and Health History Form Date First Name Middle Name Last Social Security Number Spouse First Name Middle Name Spouse Last Name Social Security Number Email Address Suite, ect. City State Zip Code Primary Phone Number Gender at Birth Male Female Marital Status Married Single Divorced Prefer Not to Say Patient Birth Date Patient Employer Occupation/ Field of Study Spouse Birth Date Spouse Employer/School Occupation/Field of Study Whom May We Thank For Reffering You? Whom is Responsible for the Account? Relationship to Patient Insurance Company Group Number Identification Number Subscribers Birthdate Subscribers Social Security # Patient Additional Insurance Coverage Yes No Relationship to Patient Insurance Company Group Number Identification Number Subscribers Name Subscribers Birthdate Subscribers Social Security # I certify that I, and/or my dependents(s), have insurance coverage with and assigned directly to Dr. Santoliva ASSIGNMENT & RELEASE All insurance benefits, any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above named doctor may use my health care information and may disclose such information to the above named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below. Assignment & Release Signature Date Relationship to Patient Contact Cell Phone Contact Home Telephone In Case of Emergency Contact Emergency Contact Relationship In Case of Emergency Contact Emergency Contact Relationship Is the condition due to an accident? Yes No Date of Accident Type of Accident Work Auto Home Other If Other, Please Specify To Whom Have You Reported the Accident to Auto Insurance Employer Worker Comp. Other If Other Please Specify Attorney Name (if applicable) REASON FOR VISIT When did your symptoms appear? Are your symptoms getting progressively worse? Yes No Type of Pain Sharp Burning Dull Tingling Throbbing Cramps Numbness Stiffness Aching Swelling Shooting How Often Do You Have the Pain? Is the Pain Constant or Does it Come & Go?? Activities or Movements That are Painful to Perform Sitting Standing Walking Bending Lying Down Does it Interfere With Your; Work Sleep Daily Routine Recreation What Treatment Have you Already Received for your Condition? Medications Surgery Physical Therapy Chiropractic Serivices None Other If Other Name and Address of Doctor who have treated you for your Condition Date of Last Exam Date of Last X-Ray of the Spine Date of Last X-Ray of the Chest Date of Last X-Ray of the Spine Date of Last X-Ray of the Spine Date of Last Dental X-Ray Date of Last Blood Test Date of Last Urine Test Date MAI, CT-Scan, Bone Scan Place a mark to indicate if you have had any of the following: AIDS/HIV Alcoholism Allergy Shots Anemia Anorexia Appendicitis Arthritis Asthma Bleeding Disorders Breast Lump Bronchitis Bulimia Cancer Cataracts Chemical Dependency Chicken Pox Diabetes Emphysema Epilepsy Fractures Glaucoma Goiter Gonorrhea Gout Heart Disease Hepatitis Hernia Herniated Disk Herpes High Blood Pressure High Cholesterol Kidney Disease Liver Disease Measles Migraine Headaches Miscarriage Mononucleosis Multiple Sclerosis Mumps Osteoporosis Pacemaker Parkinson's Disease Pinched Nerve Pneumonia Polio Prostate Problem Prosthesis Psychiatric Care Rheumatoid Arthritis Rheumatic Fever Scarlet Fever Sexually Transmitted Disease Stroke Suicide Attempt Thyroid Problems Tonsillitis Tuberculosis Tumors, Growths Typhoid Fever Ulcers Vaginal Infections Whooping Cough Exercise None Moderte Daily Heavy Work Activity Sitting Standing Light Labor Heavy Labor Smoker Yes No Packs Per Day Alcohol Yes No Drinks Per Day Caffeinated Drinks:Cups/Per Day High Stress Level/Reason? Are You Pregnant? Yes No Due Date? Injuries Or Surgeries? Yes NO Falls/Description Broken Bones/Date//Description Head Injuries/Date//Description Dislocations/Dates//Description Surgeries/Dates/Description Medications Vitamins/Herbs/Minerals Allergies Send Contact Us With Questions
