Home
About Us
Services & Techniques
Conditions Treated
Contact Us
- Appointment Request
Patient Center

Call To Action

Home
About Us
Services & Techniques
Conditions Treated
Contact Us
- Appointment Request
Patient Center

(859) 781-8700

Home

New Patient Registration Form

New Patient Registration Form

Patient Information

Date

Name*

Email *

Phone *

Complete Address*

Date of Birth

Sex

Male Female

Marital Status

Single Married Divorced Separated Widowed

Spouse

Do you have any children

Yes No

How Many

Referred to this office by

Employment Information

Employer*

Employer Complete Address*

Phone *

Occupation

Emergency Contact

Name*

Relationship*

Phone *

Who is your medical doctor

Office location

Insurance Information

Insurance Company

Insurance Type

Health Auto Worker's Comp Medicare I hereby autorize assignment of insurance benefits directly to provider for services rendered

*Please bring your insurance card and ID to your first visit

Account Information

Person Responsible for Account

Relationship

Complete billing address if different from patient address

Phone

Patient Condition

Reason for visit*

When did your symptoms begin?

Is this due to an accident?

Yes No

If Yes

Auto Work Sports Other

Other

Have you had this condition before?

Yes No

If yes, when

Describe your complaint and its location*

Is it getting worse?

Yes No Constant Comes and goes Chronic

Rate your pain: 0 = no pain, 10 = unbearable*

Does it interfere with daily activities?

Yes No

If yes, explain

Do you have:

Numbness Tingle

Location

What have you tried to relieve the problem(s)?

Have you seen anyone else for this condition?

Yes No

If yes, who

Have you ever been treated by a chiropractor?

Yes No

If yes, what's the doctor's name and location?

Patient Health History

Are you currently taking any of the following? (Please list and give reason for taking)

Prescription medications

Over the counter medications

Vitamins/supplements

Do you currently have or have had any of the following diseases/medical condition?

heart Attack Congenital heart defect High blood pressure Low blood pressure Headaches Heart surgery Pacemaker Dizziness/Fainting Anemia Shingles Prostate trouble Appendicitis Low back pain Neck pain Stroke Difficulty Breathing Emphysema Asthma Allergies Sinus Trouble Kidney problems Venereal disease Ulcers/Colitis Diabetes HIV/AIDS Miscarriage Vision problems Thyroid problems Arthritis Gout Polio Chicken Pox Scoliosis Mental illness Multiple sclerosis Tuberculosis Seizures/Epilepsy Hepatitis Fibromyalgia Rheumatoid arthritis Pneumonia Hearing trouble Hearing trouble Digestive problems Artificial joints Pinched nerve Fractures Implants Cancer/tumors *

Cancer/tumors * Type

Date of diagnosis

Treatment

Current status

Please list any other serious medical condition(s) you have ever had

List any surgeries/treatment/hospitalizations with dates

List any past serious accidents/injuries/broken bones/dislocations with dates

Family health history

Do you participate in any physical activity?

Do you smoke?

Do you drink alcohol?

Do you drink coffee/caffeine drinks?

Do you have high stress levels?

Do you wear

Heel lifts arch supports/orthotics

Do you have foot pain?

Yes No

Does your job require

Sitting Standing Lifting

Hours of sleep per night

For women

Yes No

if yes, weeks and Due date

Nursing

Yes No

Are you on birth control?

Yes No

Upon submitting this form, I understand the information contained within this form and guarantee this form was completed correctly and to the best of my knowledge.

Patient / Guardian

Date

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

Error!

Location

Find us on the map

--mi

Douglas P Krift DC

Address

1467 S Ft Thomas Ave
Fort Thomas, KY 41075

Contact Information (859) 781-8700

[email protected]

Office Hours

Monday

9:00 am - 12:00 pm

2:00 pm - 6:00 pm

Tuesday

Closed

Wednesday

9:00 am - 12:00 pm

2:00 pm - 6:00 pm

Thursday

9:00 am - 12:00 pm

2:00 pm - 6:00 pm

Friday

9:00 am - 12:00 pm

2:00 pm - 6:00 pm

Saturday

Closed

Sunday

Closed

1467 S Ft Thomas Ave
Fort Thomas, KY 41075

(859) 781-8700

Admin Log In
Site Map