Doctor s Personal Information Form

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1 1 Doctor s Personal Information Form Please complete as much of the following information as possible. Section #1: Personal Information Doctor s Name: First Name Middle Initial Last Name Name of Your Corporation: Male Female Marital Status: Single Married Home Street Address: Town State Zip Code Home Telephone #: Cell Phone #: Office Street Address: Town State Zip Your office is near the corner of and. Office Telephone #: Office Fax #: Home Address: Office Address: Office Web Site Address: Date of Birth: Doctor s Hometown: Spouse s Hometown: Town you were raised in: State you were raised in: Number of Children Children s Names:.

2 2 Civic Clubs (Past, Present & Offices Held):_ Hobbies: Any family or business association you may have had within ten miles of your office site that local people might recognize or relate to: The reason you chose the town in which to practice: The progressiveness of the town. The friendliness of the people The beauty of the area. Other (These should be things that the people of the area are proud of or anything you feel you could fall in love with.)

3 3 Section #2: Professional References Doctor, list the name, title or position (Dr., Attorney at Law, CEO of ABC, Inc., etc.) address and telephone number of 4 to 6 different professionals you will use as references. Only list those professionals you are 100% sure of being great references for you. Reference #1: Name: Title or Position & Name of Company: Telephone Number (including Area Code): Reference #2: Name: Title or Position & Name of Company: Telephone Number (including Area Code): Reference #3: Name: Title or Position & Name of Company: Telephone Number (including Area Code): Reference #4: Name: Title or Position & Name of Company: Telephone Number (including Area Code): Reference #5: Name: Title or Position & Name of Company: Telephone Number (including Area Code): Reference #6: Name: Title or Position & Name of Company: Telephone Number (including Area Code): Section #3: Educational Information High School: City State Undergraduate College: City State

4 4 Was a Degree Granted? YES NO Name of the Degree Earned (If any) List the Year(s) studied at this facility (e.g. From 1978 to 1979): From to Honors Do you have another Undergraduate College to list? YES NO. Undergraduate College: City State Was a Degree Granted? YES NO Name of the Degree Earned (If Any) List the Year(s) studied at this facility (e.g. From 1978 to 1979): From to. Honors Do you have another Undergraduate College to list? YES NO Undergraduate College: City State Was a Degree Granted? YES NO Name of the Degree Earned (If Any) List the Year(s) studied at this facility (e.g. From 1978 to 1979): From to. Honors Chiropractic College: City State Required years of study Have you graduated? YES NO When do you expect to graduate? Month: Year: Year Graduated Month Graduated Did you graduate Magna Cum Laude? YES NO Did you graduate Cum Laude? YES NO Internship from (year) through (year)

5 5 Check off the Elective Courses you took while in Chiropractic College: X-Ray Intern X-Ray Diagnosis Physiotherapy Applied Kinesiology Motion Palpation Gonstead Pelvic Bench Technique Biomechanics of the Spine Renaissance Seminars Biology Organic and Inorganic Chemistry Psychology Other Did you receive Special Training while in Chiropractic College, (e.g. Neurology Diplomate Program, Radiology Red Badge, Adjusting Techniques, Unit Director, etc.)? YES NO Doctor, please list one Special Training item at a time: Name of Training Received: Name of Facility Who Gave the Training: Location of Facility: City: State: Year(s) in which you received the training: Did you receive any other Special Training while in Chiropractic College? YES NO Name of Training Received: Name of Facility Who Gave the Training: Location of Facility: City: State: Year(s) in which you received the training: Did you receive any other Special Training while in Chiropractic College? YES NO Name of Training Received: Name of Facility Who Gave the Training: Location of Facility: City: State: Year(s) in which you received the training: Did you receive any Special Honors or Awards while in Chiropractic College: YES NO Name of Award or Honor: Award was received from whom? Did you receive any other Special Honors or Awards while in Chiropractic College: YES NO Name of Award or Honor: Award was received from whom? Did you receive any other Special Honors or Awards while in Chiropractic College: YES NO Name of Award or Honor: Award was received from whom? Did you receive any other Special Honors or Awards while in Chiropractic College: YES NO Name of Award or Honor: Award was received from whom?

6 6 Any Offices Held in any Organizations or Classes While in Chiropractic College: Organization: Position Held: Teaching Assistant & List Subjects: National Board:. Fraternities/Sororities:. Have you taken any College sponsored Post-Graduate courses? YES NO Post-Graduate College/Seminars: Name of College sponsoring the Post Graduate Course Location of College: City State Type of seminar/study: Name of Degree or Certification Earned Date or Year in Which Degree or Certificate was earned: Number of hours studied Do you have another College sponsored Post-Graduate course to list? YES NO Name of College sponsoring the Post Graduate Course Location of College: City State Type of seminar/study: Name of Degree or Certification Earned Date or Year in Which Degree or Certificate was earned: Number of hours studied Do you have another College sponsored Post-Graduate course to list? YES NO Name of College sponsoring the Post Graduate Course Location of College: City State Type of seminar/study: Name of Degree or Certification Earned Date or Year in Which Degree or Certificate was earned: Number of hours studied Have you taken any Post-Graduate courses that were NOT sponsored by a College? YES NO Post-Graduate Training/Seminars - Non College Sponsored Who sponsored the course: Sponsor s Address: City State Type of seminar/study: Name of Degree or Certification Earned: Date or Year in Which Degree or Certificate was earned: Number of hours studied

7 7 Have you taken any other Post-Graduate courses that were NOT sponsored by a college? YES NO Post-Graduate Training/Seminars - Non College Sponsored Who sponsored the course: Sponsor s Address: City State Type of seminar/study: Name of Degree or Certification Earned: Date or Year in Which Degree or Certificate was earned: Number of hours studied Have you taken any other Post-Graduate courses that were NOT sponsored by a College? YES NO Post-Graduate Training/Seminars - Non College Sponsored Who sponsored the course: Sponsor s Address: City State Type of seminar/study: Name of Degree or Certification Earned: Date or Year in Which Degree or Certificate was earned: Number of hours studied Were you a Professor s Assistant for any College sponsored Post-Graduate course? YES NO Teaching Assistant at Post-Graduate courses: Name of College: Location of College: City: State: Name of course: Were you a Professor s Assistant for any other College sponsored Post-Graduate course? YES NO Teaching Assistant at Post-Graduate courses: Name of College: Location of College: City: State: Name of course: Were you a Professor s Assistant for any other College sponsored Post-Graduate course? YES NO Teaching Assistant at Post-Graduate courses: Name of College: Location of College: City: State: Name of course: Were you a Professor s Assistant for any other College sponsored Post-Graduate course? YES NO Teaching Assistant at Post-Graduate courses: Name of College: Location of College: City: State: Name of course:

8 8 List any clinics visited where you learned by watching the clinic s operation. Name of Clinic City State List the duties and procedures you observed while visiting this clinic: Name of Clinic State List the duties and procedures you observed while visiting this clinic: Section #4: Professional Licenses & Affiliations Association Affiliations, i.e., ICA, ACA, WCA, Chiropractic College Alumni Association, etc. Name Year Joined: Name Year Joined: Name Year Joined: Name: Year Joined: Name: Year Joined: State Licenses States Licensed In Month & Year First Licensed License Certificate Number Passed National Board of Chiropractic Examiners (year) National Board of Chiropractic Examiners Certificate # Section #5: Previous Practice Experience Where: Name of Clinic: Street Address City State From (Year to (Year) Position or Job Title (Associate, Clinical Preceptorship, etc.) Duties Performed: Doctor the following is a SAMPLE of the format that you should use in answering this question: Sole chiropractic physician at office seeing patients per week. Responsible for entire case management of patient from initial examination, consultation, x-rays, report of findings, therapy and adjustments. Write patient narratives to attorneys and insurance

9 9 companies as required. Conduct both public and patient lectures weekly, on various health topics, perform outside health screenings and back safety lectures to employees of local businesses. Where: Name of Clinic Street Address City State From (Year to (Year) Position or Job Title (Associate, Clinical Preceptorship, etc.) Duties Performed: Doctor the following is a SAMPLE of the format that you should use in answering this question: Sole chiropractic physician at office seeing patients per week. Responsible for entire case management of patient from initial examination, consultation, x-rays, report of findings, therapy and adjustments. Write patient narratives to attorneys and insurance companies as required. Conduct both public and patient lectures weekly, on various health topics, perform outside health screenings and back safety lectures to employees of local businesses. Section #6: Previous Professional Experience Other Than Chiropractic Date Position or Job Title Name of Clinic Street Address City State Duties Performed Date Position or Job Title Name of Clinic Street Address City State Duties Performed Date Position or Job Title Name of Clinic Street Address City

10 10 State Duties Performed Section #7: Professional Preferences ADJUSTING TECHNIQUES YOU WILL UTILIZE Activator Flexion Distraction (COX) ProAdjustor (or similar technique) Thompson Upper Cervical Cranial Technique DeJarnette (SOT) Diversified (Full Spine) Gonstead Applied Kinesiology Nimmo Soft Tissue Technique CBP & Pettibon Logan Basic Woggon - Scoliosis Other (Please Explain) Other (Please Explain) Do you plan to offer a Free Consultation, Free Examination or Free Spinal Screening Examination to prospective patients? Yes No If Yes Are you planning to offer a Free Consultation Free Examination Free Spinal Screening Examination. Please write your State s Advertising Disclaimer (If any):. Are you a member of your city s Chamber of Commerce? Yes No Name of Chamber of Commerce: Section #8: Print Media Contacts Please provide the names & addresses of the newspapers you intend to send opening announcement or health survey press releases to: Name of Newspaper: Name of Health Editor: Address of Newspaper: Address: Fax Number: Name of Newspaper: Name of Health Editor: Address of Newspaper: Address: Name of Newspaper: Name of Health Editor: Address of Newspaper: Address: Fax Number: Name of Newspaper: Name of Health Editor: Address of Newspaper: Address:

11 11 Fax Number: Name of Newspaper: Name of Health Editor: Address of Newspaper: Address: Fax Number: Name of Newspaper: Name of Health Editor: Address of Newspaper: Address: Fax Number: Fax Number: Name of Newspaper: Name of Health Editor: Address of Newspaper: Address: Fax Number: Name of Newspaper: Name of Health Editor: Address of Newspaper: Address: Fax Number: On what date do you want the PCSA Release sent to the newspaper(s)?. ###

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