Get Confidential Patient Information ... - Alignlife.com

Completing the confidential patient information form is a vital step in your healthcare journey. This guide provides clear, step-by-step instructions to help you navigate each section of the form, ensuring that you provide all necessary information comfortably and accurately.

Follow the steps to effectively complete your form.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Begin by filling in your personal information, including your full name, date, Social Security Number, home phone, cell phone, address, city, state, zip code, sex, age, birth date, marital status, number of children, occupation, and employer details.
3. In the spouse section, provide your partner's name and occupation, and also thank the person who referred you, if applicable.
4. Indicate whether you have previously received chiropractic care, including the name of the doctor and the date of your last visit.
5. Select your preferences regarding reminders, whether by email or text, and include your cellular carrier if choosing text reminders.
6. List any recent traumas you may have experienced, such as auto accidents or major injuries, along with the dates.
7. Describe your primary condition, including when it started, if you have experienced it in the past, and mark your areas of pain on the accompanying figure.
8. Indicate the nature of your pain (e.g., constant or intermittent) and rate it on a scale from 1 to 10.
9. Complete the follow-up sections for additional conditions, if applicable, using the same guidelines provided for the primary condition.
10. Fill out the sections regarding activities of daily living, medications, nutrients, and family history.
11. Answer any lifestyle questions to provide insights into your diet and exercise habits.
12. Review and sign the patient consent form, as well as the terms of acceptance and financial arrangements, ensuring all information is accurate.
13. After completing all sections, you can save the changes, download, print, or share the form as required.

Start filling out your confidential patient information form online today!