Welcome

Bedford Center Chiropractic
Anna Petrella, D.C.

Thank you for choosing our practice for your chiropractic needs. Please complete this form. If you have any questions or concerns,
do not hesitate to ask for assistance. We will be happy to help. Please be advised that all information on this form is confidential andno information will be released without your consent.

Patient Information
Name ___________________________________________ Date_________________ Gender □ M □ FAddress ______________________________________ City, State, Zip ___________________________
Home Phone _________________Cell Phone __________________Work Phone ____________________
Best place to reach you? □ Home Phone□ Cell Phone□ Work Phone□ Email _______________________________________________________□ Texting_________________
Patient Employer/School __________________________________ Occupation______________________
Birth Date _________ Age____ □ Single □ Married □ Widowed □ Divorced □ Partnered □Minor
Spouse/Significant Other/ or Parent’s name _______________________ Number of Children_________
Whom may we thank for referring you to us? ________________________________________________
Person to contact in case of emergency____________________________ Phone ____________________

Patient Condition
Reason for Visit ________________________________________
When did you first notice the symptoms? ___________________Is this condition getting progressively worse? □ Yes □ No □ Unsure
Is this condition due to an accident? □ Yes □ No
Type of Accident □ Auto □ Work □ Home □ Other

Date ___________**If auto or work accident, please visit front desk for additional forms.
Where specifically is the problem(s) located? _________________________Mark an “X” on the pictureMark an X on the picture where you continue to have pain, numbness, or tingling.
My current pain/problem can be described as (check all that apply):□ Sharp□ Tingling□ Dull□ Throbbing□ Cramping□ Numbness□ Stiffness□ Aching□ Swelling□ Shooting□ Spasms□ Burning□ OtherRate the severity of your pain. 1 (least pain) to 10 (severe pain) _______Is the pain constant or does it come and go? _______________________
Does it interfere with your□ Work□ Sleep□ Daily Routine

Activities or movements which are painful to perform: □ Sitting□ Bending□ Lying Down

Is the pain worse: □ AM

□ Recreation□ Standing □ Walking□ PMWhat treatment have you already received for your condition? □ Medication □ Surgery□ Physical Therapy □ Chiropractic Services □ None □ Other _________________________Name and address of other doctor(s) who have treated you for this condition:________________________________________________________________________________

Health History (Please circle all that apply)
AIDS/HIV
AlcoholismAllergy Shots
AnemiaAnorexia
Appendicitis
Arthritis
AsthmaBells Palsy
Bronchitis
Bulimia
CancerCataracts
Chemical Dependency

Chicken Pox
Depression
Diabetes
Emphysema
Epilepsy
Fractures
Glaucoma
Gout
Headaches/Migraines
Heart Disease
Hepatitis
HerniaHerniated DiscHigh Cholesterol

Kidney Disease
Liver Disease
Measles
Miscarriage
Mononucleosis
Multiple Sclerosis
Osteoporosis
Parkinson’s Disease
Pneumonia
Prostate Problems
Prosthesis
Psychiatric Care
Rheumatoid Arthritis
ShinglesStrokeSuicide Attempt
Thyroid Problems
Tumors, Growths
UlcersVaginal Infections
Venereal Disease
VertigoWhooping CoughOther ___________

Dates of last exams______________________________________________________________(Women) Are you pregnant? □ Yes □ NoNursing? □ Yes □ No

List any types of surgeries which you have had and the dates which they occurred:________________________________________________________________________________________
Please list all medications you are currently taking: ___________________________________________________________________________________________________________________________________
Allergies: _______________________________________________________________________________

Daily Habits
What type of exercise do you perform on a daily basis? □ None

□ Moderate□ Heavy

Daily work habits include: □ Sitting □ Standing □ Light Labor □ Heavy Labor □ Computer Work
What vitamins and/or nutritional supplements do you currently take?
_________________________________________________________________________________________
Do you smoke? □ No □ Yes

How much alcohol do you consume on a weekly basis? _______________How much coffee or caffeinated beverages do you consume on a daily basis? _______________________

Certification and Assignment
To the best of my knowledge, the above information is complete and correct. I understand that it is myresponsibility to inform my doctor if I, or my minor child, ever have a change in health.
I certify that I, and/or my dependent(s), have insurance coverage with _____________________________
and assign directly to Dr. Anna Petrella all insurance benefits, if any, otherwise payable to me for services
rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. Iauthorize the use of my signature on all insurance submissions.
The above-named doctor may use my health care information and may disclose such information to the abovenamed Insurance Company(ies) and their agents for the purpose of obtaining payment for services anddetermining benefits or the benefits payable for related services.
______________________________________________________________________________________

Signature of Patient, Parent, Guardian or Personal Representative

Date______________________________________________________________________________________

Please print name of Patient, Parent, Guardian or Personal Representative

Date