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Name ______________________________________
Address ____________________________________
Age __ Birth Date _______ Marital Status M S W D
Occupation _________________________________
Address ____________________________________
Name of Wife or Husband ______________________
Employer ___________________________________
Patient's Nearest Relative ______________________
Address ____________________________________
Referred by _________________________________
Date of last physical examination ______________
Have you ever suffered from:

Purpose of
this Appointment ____________________________________________________________________
Other Doctors seen for this condition: ___________________________________________________

Have you been treated for any health condition by a physician in the last year? Yes No
Describe: __________________________________________________________________________
Remarks and additional information: ____________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

PAYMENT IS EXPECTED AT THE TIME OF VISIT!
Name of Person Responsible for Payment: ______________________________________
Are you Insured? Yes No Company: _________________________________

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that Nunez Chiropractic Center 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 Nunez Chiropractic Center 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 my care and treatment, any fees for professional services rendered me will be immediately due and payable.

Patient's Signature: _____________________________________________ Date: _____________
Guardian or Spouse's Signature ___________________________________ Date: _____________
Information taken By: ____________________________________________ Date: _____________

	Yes	No		Yes	No
1. Dizziness			8. Asthma
2. Backaches			9. Neuritis
3. Heart Trouble			10. Digestive Disorder
4. Diabetes			11. Nervousness
5. Tuberculosis			12. Sinus Trouble
6. Arthritis			13. Anemia
7. Headaches			14. Cancer