Patient Center
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Resources
Contact
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James Frandanisa, D.C.

James Frandanisa, DC

Patient Center
Services
About Us
- Meet the Doctor
Resources
Contact
- Appointment Request

(253) 582-2122

James Frandanisa, DC

Patient Center
Services
About Us
- Meet the Doctor
Resources
Contact
- Appointment Request

(253) 582-2122

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New Patient Health History Form

New Patient Health History Form

Patient Data

First Name*

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Last Name

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Date

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Email *

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Mailing address

Address

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City

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State

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Zip

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Telephone (Work) *

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(home)

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Referred By

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Age

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Birth Date

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Social Security #

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Number of Children

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Occupation

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Employer

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Marital Status

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Spouse's Name

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Spouse's Occupation

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Spouse's Employer

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Spouse's Health Status

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Emergency Contact

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Phone

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Current Complaints

Nature of Injury

Automobile New Work Other

Please describe

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Date of Injury

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Date symptoms appeared

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Have you ever had same condition?

Yes No

If yes, when?

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List of other practitioners seen for this injury/condition

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Have you ever been under chiropractic care?

Yes No

If yes, please describe

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Insurance Information

Name of party responsible for payment

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Phone

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Do you have health insurance?

Yes No

Name of company

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* If an auto accident, please provide:

Insurance Company Name

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Contact Person

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Phone

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Claim #

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Signatures

Name of the insured

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I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Patient’s s Name

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Spouse’s or guardian’s name

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Medical History

Have you been treated for any conditions in the last year?

Yes No

If yes, please describe

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Date of last physical exam

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Is there a chance that you are pregnant?

Yes No

Have you had X-rays taken?

Yes No

If Yes, where?

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What medications are you taking and for what conditions (Please list dosage and amounts, etc)l

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Have you ever

Broken bones?

Yes No

Briefly Explain

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Been hospitalized?

Yes No

Briefly Explain

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Been in an auto accident?

Yes No

Briefly Explain

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Had Sprains/Strains?

Yes No

Briefly Explain

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Been struck unconscious?

Yes No

Briefly Explain

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Had surgery?

Yes No

Briefly Explain

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Family History

Family Members - Present and past health conditions (Example: heart disease, cancer, diabetes, arthritis, etc.)

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Do you experience pain every day?

Yes No

Do your symptoms interfere with daily life?

Yes No

Does pain wake you up at night?

Yes No

Are your symptoms worse during certain times of the day?

Yes No

Do changes in weather affect your symptoms?

Yes No

Do you wear orthotics?

Yes No

Do you take vitamin supplements?

Yes No

What activities aggravate your symptoms?

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Habits

Alcohol

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Coffee

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Tobacco

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Drugs

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Exercise

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Sleep

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Appetite

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Soft Drinks

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Water

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Salty Foods

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Sugary Foods

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Artificial Sweeteners

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Have you ever suffered from

Alcoholism Allergies Anemia Arteriosclerosis Arthritis Asthma Back Pain Breast Lump Bronchitis Bruise Easily Cancer Chest Pain/Conditions Cold Extremities Constipation Cramps Depression Diabetes Digestion Problems Dizziness Ears Ring Excessive Menstruation Eye Pain or Difficulties Fatigue Frequent Urination Headache Hemorrhoids High Blood Pressure Hot Flashes Irregular Heart Beat Irregular Cycle Kidney Infection Kidney Stones Loss of memory Loss of balance Loss of smell Loss of taste Lumps In Breast Neck Pain or Stiffness Nervousness Nosebleeds Pacemaker Polio Poor Posture Prostate Trouble Sciatica Shortness of breath Sinus Infection Sleep problems or Insomnia Spinal Curvatures Stroke Swelling of ankles Swollen Joints Thyroid Condition Tuberculosis Ulcers Varicose Veins Venereal Disease Other

Please indicate others

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Thank you. Your submission has been sent.

Visit our Office

--mi

Address

6923 Lakewood Dr W STE B3
Tacoma, WA 98467, US

Contact Information (253) 582-2122

James Frandanisa, DC

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