Cigna/ASH Health History Form

Full Name *

Birthdate *

Sex *

Address, City, State, Zip *

Phone *

Patient Primary Language *

Occupation *

Employer

Work Phone

Subscriber Name *

Health Plan

Subscriber ID # *

Group #

Spouse Name

Spouse Employer

Address, City, State, Zip

Primary Care Provider

What is the nature of your problem? *

Describe your symptoms and how they began: *

Date your problem began? *

Current Complaint (how you feel today): *

How often are your symptoms present? *

(0-25%) Occasional

(26-50%)

(51-75%)

(76-100%) Constantly

In the past week, how much has your pain interfered with your daily activities (e.g., work, social activities, or household chores?) *

In general would you say your overall health right now is: *

What is your height? *

What is your weight? *

HAVE YOU HAD SPINAL X-RAYS, MRI, CT SCAN FOR YOUR AREA(S) OF COMPLAINT *

If yes, what was it, when, and where?

Please check all of the following that apply to you (If yes, explain in next section):: *

If you checked a box with a (), please list the item and provide the requested specifics:

Family History: *

I certify to the best of my knowledge, the above information is complete and accurate. If the health plan information is not accurate, or if I am not eligible to receive a health care benefit through this practitioner, I understand that I am liable for all charges for services rendered and I agree to notify this practitioner immediately whenever I have changes in my health condition or health plan coverage in the future. I understand that my chiropractor may need to contact my physician if my condition needs to be co-managed. Therefore I give authorization to my chiropractor to contact my physician, if necessary. *

I certify and give authorization

I do not certify and give authorization

Please fill-out the form to the best of your ability. We will review all the information at your visit.

If a question is required but you don’t have an answer, you can respond with “N/A.”

Like this:

Please fill-out the form to the best of your ability. We will review all the information at your visit.

***If a question is required but you don’t have an answer, you can respond with “N/A.”***

Share this:

Like this:

If a question is required but you don’t have an answer, you can respond with “N/A.”