Dr Mark LaRue DC
 Printable Version or email to: markslarue@comcast.net  or fax to 360 666-4969
Battle Ground Family Chiorpractic
Mark S. LaRue D.C. 713 W Main St. Battle Ground, WA. 98604
(360) 666-4969
Initial Health Status
Patient Name:_____________________________________Birthdate:________________________Sex: M / F
Address:_______________________________City:______________________State:_______________Zip:________
Telephone:______________________Cell Phone:_______________________Work Phone:_____________________
Social Security #:_______________________________Drivers License #:___________________________________
Occupation:_______________________________________Employer:______________________________________
Address:_______________________________City:______________________State:_______________Zip:________
Subscriber Name:_______________________________Health Plan:________________________________________
Subscriber ID #:__________________________Group #:___________________Spouse Name:__________________
Spouse Employer:_______________________City:______________________State:_______________Zip:________
E-Mail Address:______________________________________Referred By:__________________________________
MARK AN X ON THE PICTURE WHERE YOU HAVE PAIN OR OTHER SYMPTOMS.
Discribe your current problem and how it began:
______________________________________________                        
______________________________________________
______________________________________________
______________________________________________                     
Is this:     __ Work Related     __ Auto Related     __ N/A
What Is The Date Problem Began:__________________
Current complaint (how you feel today):
       ===============================================
        0      1      2      3      4      5      6      7      8      9      10
    No Pain                                                      Unbearable Pain
How often are your symptoms present?          __ 0-25%          __ 26-50%          __ 51-75%         __ 76-100%
Can you preform your daily activities?           __ Yes           __ No   (Describe)____________________________
_______________________________________________________________________________________________
Have you had a spinal X-Ray, MRI, or CT Scan?       __ No       __ Yes     Date(s) taken:_____________________
If so, what areas were taken?_______________________________________________________________________
Please check all the following that apply to you:
Past    Present   Conditons                                                        Past    Present   Conditons 
 _      _ Hisory of Recent Infection                                            _      _ Prostate Problems
 _      _ Fever                                                                         __       _  Frequent Urination
 _      _ HIV/AIDS                                                                     _     _   Pregnancy, # of births________
 _      _ Diabetes                                                                      __      _ Abnormal Weight___Gain___Loss
 _      _ Corticosteroid Use                                                       _      _ Epilepsy/Seizures
 _      _ Birth Control Pills                                                         _      _ Visual Disturbances
 _      _ High Blood Pressure                                                    _      _ Low /Mid Back Pain
 _      _ Stroke (date)_______________                                    _      _ Neck Pain
 _      _ Dizziness/Fainting                                                        _      _ Arthritis
 _      _ Numbness in Groin/Buttocks                                        _      _ Alcohol Use
 _      _ Urinary Retention                                                         _      _ Tabacco Use
 _      _ Aortic Aneurysm                                                          __      _ Surgeries/Medications
 _      _ Cancer/Tumor                                                              _____________________________________
 _      _ Osteoporosis                                                                _____________________________________
Faimily History:       __ Cancer       __ Diabetes     __ High blood pressure     __ Cardiovascualr Problems
I certify that the above information is complete and accurate. If the health plan information is not 
acurate, or if I am not eligible to receive a health care benefit through this provider, I understand that I
am liable for all charges for services rendered and I agree to notify this docotor immediately whenever I
have changes in my health condition or health plan coverage in the future. 
Patient Signature:____________________________________ Date:__________________
Parent or guardian consent to treat a minor must sign