Current Patient Not Calendar Year

Weis Chiropractic & Physical Therapy Center 
CONFIDENTIAL PATIENT INFORMATION FORM – ROP
10671 McSwain Drive
Cincinnati, OH  45241
Voice: 513.563.0414 * FAX 513.563.9540 * Web: www.weischiro.com * email: weischiro@fuse.net

Instructions

The information on this document is kept in your confidential patient file in our office as a record of your office visit. This document is to be submitted when you have not visited our office during the current calendar year.

After printing the document, please fill it out completely. Bring the completed and signed document with you to your office visit. By doing so you’ll be able to speed up the initial registration process of your office visit.

Patient Details

Last Name: ______________________________ First Name: __________________________

Middle:__________ Social Security#____________________________ DOB:________________

Marital Status: Married ___ Single ___ Divorced ___ Widowed ___

Address: ___________________________________________________ Phone: _________________

City: _______________________________________________________ State: ___

Zip Code: ________ Email Address: __________________________________

Occupation: ____________________________________

Employer Name: ________________________EmployerAddress:_____________________________

City: __________________________ State:____ Zip Code: _______ Telephone: ________________

Name of Spouse (parent, if you are a minor): _________________________ Phone:_____________

Primary Care Physician: __________________________________________________ Phone: _____________

Visit Details

Chief Complaint: _____________________________________________________________________

Date Problem Started: ________________ Auto Accident Related: Yes ___ No ___ Work Related: Yes ___ No ___

Since your last visit have you required surgery or hospitalization? Yes ___ No ___ If yes, please explain briefly the details: ___________________________________________________________________

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Since your last visit have you required treatment from another physician? Yes ___ No ___ If yes please explain briefly the details: _____________________________________________________________

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Do you suspect that you may be pregnant? Yes __ No ___

Are you currently taking any over the counter medications? Yes ___ No ___ Explain:

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Are you currently taking medications for the following: Anti-inflammatory  Muscle Relaxants  Birth Control  Blood Thinners  High Blood Pressure  Pain Relievers  Other  Explain: Have you ever been diagnosed with: High Blood Pressure  Heart Attack  Emphysema  Seizures/Convulsions  Thyroid Disease  Circulation Problems  Cancer  (If yes, please describe type of cancer: )

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Please note: payment or insurance co-payment is expected at time of visit.

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Patient Signature / Date

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