The Total Wellness Center, PA
Patient Information Form

Patient Information..........................................................Insurance
Date: Person responsible for account::
SS/HIC/Patient ID #: Relationship to patient:
Patient Name: (required) Insurance Company:
Address: Group #:
City: Additional Insurance?:
State: Subscriber's Name:
Zip: Birthdate:
Email address: (required) SS #:
Sex: Relationship to patient::
Age: Insurance Company:
Birthdate: Add Ins Group #:
Marital Status:
Occupation:
Patient Employer/School:
Employer/School Address:
Employer/School Phone #:
Spouse's Name:
Spouse's SS#:
Spouse's Employer:
Whom may we thank for this referral?:
Assignment and Release
I certify that I, &/or my dependant(s), have insurance coverage with
Name of Insurance Company:
and assign directly to Dr. Spacke all insurance benefits, if any, otherwise payable to for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above named Dr. may use my health care information and may disclose such information to the above named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Please electronically sign this aggreement by filling out the following fields:

Patient, Guardian or Personal Representative:
Date:

Relationship to Patient:


Phone Numbers..........................................................Accident Information
Home Phone: Is condition due to an accident?:
Cell Phone: Date of accident:
Best time to reach you: Type of accident:
Emergency Contact: To whom have you reported your accident?:
Relationship: Attorney Name (if applicable):
Home Phone:
Work Phone:
Patient Condition
Reason for visit:


When did your symptoms appear?:


Is this condition getting progressively worse?:


Where exactly do you continue to have pain, numbness or tingling?


Rate the severity of your pain on a scale of 1 (least pain) to 10 (severe pain):

Sharp: Burning: Dull:
Tingling: Throbbing: Cramps:
Numbness: Stiffness: Aching:
Swelling: Shooting: Other:

How often do you have this pain?

Is it constant or does it come and go?

Does it interfere with your:

Activities or movements that are painful to perform:

Health History
Please check the box to indicate if you have had any of the following:
AIDS/HIV Goiter Pneumonia
Alcoholism Gonorrhea Polio
Allergy Shots Gout Prostate Problem
Anemia Heart Disease Prosthesis
Anorexia Hepatitis: Psychiatric Care
Appendicitis Hernia Rheumatoid Arthritis
Arthritis Herniated Disk Rheumatic Fever
Asthma Herpes Scarlet Fever
Bleeding Disorders High Cholesterol Stroke
Breast Lump Kidney Disease Suicide Attempt
Bronchitis Liver Disease Thyroid Problems
Bulimia Measles Tonsilitis
Cancer Migraine Headaches Tuberculosis
Cataracts Miscarriage Tumors, Growths
Chemical Dependency Mononucleosis Typhoid Fever
Chicken Pox Multiple Sclerosis Ulcers
Diabetes Mumps Vaginal Infections
Emphysema Osteoporosis Venereal Disease
Epilepsy Pacemaker Whooping Cough
Fractures Parkinson's Disease Other
Glaucoma Pinched Nerve

Exercise:

Work Activity:

Habits:
Smoking..........................Packs/Day......
Alcohol.............................Drinks/Week..
Coffee or Caffeine..........Cups/Day.......
High Stress......................Reason..........
Are you pregnant? ..................Due Date:

Injuries/Surgeries you have had:
Falls Description: Date:
Head Injuries Description: Date:
Broken Bones Description: Date:
Dislocations Description: Date:
Surgeries Description: Date:

Medications:



Allergies



Vitamins/Herbs/Minerals




Required
Please Check This Box To Signify That You Have Read And Understood Our
Notice Of Privacy Practices


Thank you for taking the time to fill out this form!

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