Patient History Questionnaire

  • Please complete and submit prior to your appointment.
  • MM/DD/YYYY
  • Chief Complaints & Symptoms

  • MM/DD/YYYY
  • (10 is the worst possible pain)
  • MM/DD/YYYY
  • (10 is the worst possible pain)
  • MM/DD/YYYY
  • (10 is the worst possible pain)
  • Functional Rating Index

    Please select the accurate description of pain associated with the following activities.
  • Example: washing, dressing, etc.
  • Example: driving, flying, etc.
  • Past History

  • Family History

    Provide information on who ( immediate family: father, mother, brother, sister) Dates, type and any other details that may be relevant.
  • Social History

  • Cups per day
  • Review Of Symptoms (Check all boxes that apply)

  • Signature & Acknowledgments

    To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform Hillsdale Chiropractic & Rehabilitation Center of any changes in medical status.
  • HIPAA Privacy Notice
    Click here to access our HIPAA Privacy Notice.
  • I acknowledge that I was provided access to a copy of the Notice of Privacy Practices. I understand I can request a copy of this notice at any time.Check box to acknowledge
  • Please Type out Full Name to digitally sign document.
  • I understand that x-ray can be hazardous to an unborn child. To the best of my knowledge I am NOT pregnant. Dr. Arnot and his associates have my permission to perform an x-ray evaluation if deemed necessary.
  • Insurance Information

    Please complete for insurance eligibility and benefit determination.
  • Thank you

    Please remember to bring any X-rays or other imaging studies you may have pertaining to your primary complaint.