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About Us
- Meet the Doctor
- Testimonials
Injury Treatment
Pain Treatment
- Chiropractic Services
- Chronic Pain & Injuries
Patient Center
Contact
- Appointment Request
Insurance We Accept

(503) 585-2585 Appoinment

Phone
(503) 585-2585

Address
1765 State St Ste A,
Salem, OR 97301

Phone
(503) 585-2585

(503) 585-2585 Appoinment

About Us
- Meet the Doctor
- Testimonials
Injury Treatment
Pain Treatment
- Chiropractic Services
- Chronic Pain & Injuries
Patient Center
Contact
- Appointment Request
Insurance We Accept

Home

Patient Registration Form (Worker's Compensation)

Patient Registration Form (Worker's Compensation)

Date

First Name*

Middle Initial

Last Name*

Phone # *

Address

Cell #

City

State

Zip Code

Work #

SSN #

DL #

Date of Birth

Age

Gender

Male Female

Emergency Contact

Phone #

Private Physician

Phone #

Where you preferred to our office by any healthcare provider?

Yes No

INSURANCE INFORMATION / METHOD OF PAYMENT

Workers Compensation Insurance General Health Insurance

Insurance Company

Phone #

Claim ADJ.

Phone #

EXT

Policy #

Group #

Claim #

PLEASE INDICATE REGION OF COMPLAINT

PLEASE INDICATE REGION OF COMPLAINT

Headache Neck Pain Upper / Mid Back Low Back Shoulder / Elbow / Wrist / Hand Hip / Knee / Ankle / Foot Abdomen / Chest Other

If other

PATIENT CONDITION

When did your symptoms appear?

Was there a specific injury

Yes No

Is this condition getting progressively worse?

Yes No Unknown

Rate the severity of your pain on a scale from 1 (Least pain) to 10 (severe pain)

Is it constant or does it come and go?

How often do you have this pain?

Does it interfere with your

Work Sleep Daily Routine Recreation

Activities that are painful yo perform

Stting Standing Walking Bending Lying

WORKERS’ COMPENSATION INJURY / EMPLOYER INFORMATION

Company Name

Address

City - State - Zip

Time of Injury

Date last worked

Briefly describe injury

Emergency Treatment? If yes, where?

Were X-rays taken?

Yes No

Where

Loss of consciousness?

Yes No

MEDICAL HISTORY

Date if last physical exam

Prior Imaging (X-rays. MRI, CT scan ETC.)

Yes No

Date

Previous Chiropractic Treatment

Yes No

Where

Arthritic Condition

Yes No

Cancer

Yes No

Diabetes

Yes No

Heath Problems

Yes No

High Blood Pressure

Yes No

Vascular Condition

Yes No

Lung Problems

Yes No

Usual Childhood Diseases

Yes No

Unusual Childhood Diseases

Yes No

Currently Pregnant

Yes No

Due Date

Recreational Drugs

Yes No

Tobacco Use

Yes No

How much

Alcohol Use

Yes No

How much

Allergies

Yes No

Birth Control Medications

Yes No

Exercise

Yes No

Moderate Daily Heavy

MEDICATIONS/ALLERGIES/INJURIES

List Medications

Allergic to Medication

Allergies

Surgeries / Hospitalizations / Injuries

Prior Auto Accidents or Work Injuries

AUTHORIZATION TO RELEASE MEDICAL INFORMATION / FINANCIAL AGREEMENT

I UNDERSTAND AND AGREE THAT REGARDLESS OF INSURANCE COVERAGE, I AM LIABLE FOR ANY CHARGES INCURRED AS A RESULT OF SERVICES RENDERED TO ME AT DC CHIROPRACTIC CENTER. IF THIS ACCOUNT IS ASSIGNED TO AN ATTORNEY FOR COLLECTION AND/OR SUIT, THE PREVAILING PARTY SHALL BE ENTITLED TO REASONABLE ATTORNEY’S FEES AND COST OF COLLECTIONS.

I AUTHORIZE RELEASE OF PATIENT MEDICAL RECORDS TO THIRD PARTIES REQUIRING THESE RECORDS FOR DETERMINATION OF FINANCIAL LIABILITY.

Signature

Date

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

Thank you. Your submission has been sent.

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DC Chiropractic Center

Address

1765 State St Ste A,
Salem, OR 97301

Phone

(503) 585-2585

View Directions

Monday

9:00 am - 6:00 pm

Tuesday

9:00 am - 4:00 pm

Wednesday

9:00 am - 6:00 pm

Thursday

9:00 am - 4:00 pm

Friday

9:00 am - 6:00 pm

Saturday

Closed

Sunday

Closed

We look forward to hearing from you

First Name*

Last Name*

Age

Home Phone

Work Phone

Email *

Address

City

State

Zip

Occupation

Hours Worked Per Week

Spouse's Occupation

Hours Worked Per Week

Symptoms

Headache/Tension Digestive Disturbance Low Back Pain Elbow Pain Nervousness Ringing in Ears Allergies Knee Pain Neck Pain Fatigue/Tired Difficulty Sleeping Pain Anywhere in Body Shoulder Pain Ankle/Foot Pain Numbing/Tingling in Arms or Hands Tension Across Top of Shoulders Pain Between Shoulder Blades Numbing/Tingling in Legs or Feet Wrist/Hand Pain Irritability Weight Trouble Hip Pain Dizziness

Other Symptoms

Which of the above bothers you the most?

How long have you been bothered by this condition?

Describe how it feels or affects you when your symptoms are at their worst

Effects

Moody Irritable Interrupt Sleep Restricted on Daily Activities

Do the symptoms above affect your work performance? If so, which of the following are affected?

Decision Making Poor Attitude Decreased Productivity Exhausted at End of Day Unable to Work Long Hours

Which of the following can be attributed to your symptoms?

Lose Patience With Spouse or Children Hinders Ability to Exercise or Participate in Sports Restricted Housefold Duties Interferes with Ability to Participate in Hobbies or Other Desired Activities

Results: If you checked any of the above items, then you could be suffering from excessive stress, structural misalignment or pinched nerves. We can help you because we gently treat your body, naturally, without drugs to remove the stress and imbalances that cause health problems. If you would like to discuss your symptoms and get information on treatment options then please contact us or let us know the best time to contact you.

Email Phone

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

Thank you. Your submission has been sent.

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