If any of the following have happened to you, give approximate dates & briefly describe injury: Auto accidents: Motorcycle accidents: Falls or other injuries: Spinal or neck injuries: Broken bones: Knocked unconscious: Surgeries: Health problems of parents: Please check any of the following that apply to your current/past medical history: Allergy Jaundice Stomach Fatigue Asthma Dentures Eczema/Hives Shoulder pain Bursitis Bruise easily Constipation Heartburn Poor circulation Diarrhea Loss of sleep Hay fever Sprained Varicose veins Excessive hunger Hiatal hernia Vomiting of blood Gall bladder trouble Nervousness Migraines Bed-wetting Depression Spitting up blood Sore throats Low backache Emphysema High blood pressure Loss of weight Painful tailbone Low blood pressure Nausea Shortness of breath Sciatica Poor appetite Tumor Hardening of arteries Spinal curvature Surgery Numbness in trouble Stiff or painful neck Weakness in arms arms/hands Hyperactivity Leg pain Slow heart beat Rapid heart beat Numbness in legs or Pain between Bad posture Difficulty swallowing feet shoulders Anemia Heart attack Stroke Arm Pain Ringing in ears Poor hearing Swollen ankles Knee Pain Angina Burning sensations Stomach ulcers Thyroid trouble Foot trouble Diabetes Frequent urination Enlarged Glands Kidney stone Gout Kidney infection Nasal congestion Bladder infection Itching Painful urination Chronic cough Poor urine control Heart disease Blood in urine Hemorrhoids Prostate trouble Cancer Swollen joints Arthritis Belching or gas Chest pain Fainting Vomiting Colon trouble Broken bones Headaches Weakness in legs Nosebleeds Rheumatic fever Tuberculosis infection Difficulty breathing Convulsions I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that the Turning Point Chiropractic Clinic 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 the Turning Point Chiropractic Clinic will be to my account on the receipt. However, I clearly understand and agree that all services rendered to 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
If any of the following have happened to you, give approximate dates & briefly describe injury: Auto accidents: Motorcycle accidents: Falls or other injuries: Spinal or neck injuries: Broken bones: Knocked unconscious: Surgeries: Health problems of parents: Please check any of the following that apply to your current/past medical history: Allergy Asthma Shoulder pain Heartburn Hay fever Hiatal hernia Migraines Sore throats Loss of weight Shortness of breath Hardening of arteries trouble Hyperactivity Numbness in legs or feet Stroke Swollen ankles Stomach ulcers Foot trouble Frequent urination Kidney stone Kidney infection Bladder infection Painful urination Poor urine control Blood in urine Prostate trouble Swollen joints Belching or gas Fainting Colon trouble Headaches Nosebleeds Tuberculosis Difficulty breathing Jaundice Bursitis Poor circulation Sprained Vomiting of blood Bed-wetting Low backache Painful tailbone Sciatica Spinal curvature Stiff or painful neck Leg pain Pain between shoulders Arm Pain Knee Pain Thyroid trouble Diabetes Enlarged Glands Gout Nasal congestion Itching Chronic cough Heart disease Hemorrhoids Cancer Arthritis Chest pain Vomiting Broken bones Weakness in legs Rheumatic fever infection Convulsions Stomach Dentures Bruise easily Diarrhea Varicose veins Gall bladder trouble Depression Emphysema Low blood pressure Poor appetite Surgery Weakness in arms Slow heart beat Bad posture Anemia Poor hearing Burning sensations Fatigue Eczema/Hives Constipation Loss of sleep Excessive hunger Nervousness Spitting up blood High blood pressure Nausea Tumor Numbness in arms/hands Rapid heart beat Difficulty swallowing Heart attack Ringing in ears Angina I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that the Turning Point Chiropractic Clinic 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 the Turning Point Chiropractic Clinic will be to my account on the receipt. However, I clearly understand and agree that all services rendered to 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