Patient Information Form

Patient Information
Name*
First Middle Last
Address*
Street Address City State ZIP Code
Home Phone*
Cell Phone
Work Phone
Email*
Enter Email Confirm Email
Date of Birth
Date Format: MM slash DD slash YYYY
Appointment reminder / messages:
- Email
- Text
Are you:*
- Male
- Female
Please check one:*
- Minor
- Married
- Divorced
- Widowed
- Single
- Separated

Daily Habits
What type of exercise do you perform on a daily basis?*
- None
- Light
- Moderate
- Heavy
What do your daily work habits include?*
(ex. sitting, standing, light labor, heavy labor, computer work)
What vitamins do you currently take?
What other nutritional supplements do you take (if any)?
Do you currently smoke or are you exposed to second hand smoke?*
- Yes
- No
How much per day?
Did you previously smoke? When?
How much liquor do you consume on a weekly basis?*
How many caffeinated beverages do you consume on a daily basis?*
(This includes coffee, tea, soda, energy drinks, etc.)

HIPAA Acknowledgement
I acknowledge having access to the Total Health of Wesley Chapel HIPAA Policy online or have been given a copy, and/or been asked by the staff of Total Health of Wesley Chapel to read a copy of their HIPAA Privacy Policy as it pertains to Total Health of Wesley Chapel.

I certify that the information provided is accurate to the best of my knowledge. I further understand that giving incorrect information can be dangerous to my health. I authorize this office to release any information, including the diagnosis and the records of any treatment or examination rendered to me during the period of such chiropractic care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to Total Health of Wesley Chapel, Inc. I further understand that my chiropractic insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services on my behalf or my dependents.
Name*
First Last
Date*
Date Format: MM slash DD slash YYYY
Informed Consent Acknowledgement
I acknowledge that I have read and understand the Informed Consent for Chiropractic Treatment and understand the risks of the recommended treatment. The treatment and the risks of the treatment, along with the alternatives to treatment including but not limited to one of the following options (orthopedic or neurosugical evaluation and/or alternative medical doctors) have also been fully verbally explained to me by the doctor. I understand and consent to treatment being delivered by Dr. Ladanyi and/or (whomever he may designate as his assistants). I nonetheless do consent for Total Health of Wesley Chapel Inc. to provide their recommended chiropractic therapy. I also certify that no guarantee or assurance of results has been made.
Name*
First Last
Date*
Date Format: MM slash DD slash YYYY

Step 1 of 5

Patient Information

Symptoms

Medical Information

Health History

For Women

Daily Habits

HIPAA Acknowledgement

Informed Consent Acknowledgement