Above & Beyond Chiropractic
213 Creekside Office Dr.
Wentzville, MO 63385
636.332.9100
www.mywentzvillechiropractor.com
www.facebook.com/abovebeyondchiro

Patient Intake Form

Welcome to our online Patient Intake Form. The information you fill in will be sent directly to our office, speed up your office visit, and will help us to better serve your healthcare needs. Please take a moment to completely fill out this form, and upon completion of all form categories click the [Submit] button at the bottom of this form.

Welcome to our office of chiropractic. Thank you for taking a moment to fill in our Patient Intake Form. Please fill this form completely and to the best of your knowledge. Let our staff know if you have any questions. When complete return it to our office with the bottom authorization checked and appropriate signatures filled in.

For your protection and security; Navigating away from this form before clicking the [Submit] button will dismiss all completed form fields. Successful submission will redirect you to a confirmation page.

Patient Information

Personal Information

Contact Information

*First Name:
Middle Name:
*Last Name:
*Gender:	Female Male
*Date of Birth:
Social Security #:
Height:	Feet Inches
Weight:
Marital Status:
Spouse's Name:
Number of Children:

Emergency Contact:
Relationship:
Phone:

*Email:
	(We will NOT share your email with any third party. We will only use your email to contact you in relation to your care with our practice.)
*Home Phone:
Cell Phone:
Work Phone:

Country:
Address Line 1:
Address Line 2:
City:
State/Province/Region:
*Zip/Postal Code:

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Intensive Pediatric Evaluation

COMPLETE THIS SECTION ONLY IF THE PURPOSE OF THE VISIT IS AN INTENSIVE PEDIATRIC EVALUATION.

Physical Stressors

Were there any significant falls or traumas to the mother during the pregnancy?

Yes No Unsure

List any evidence of birth trauma:

Bruising

Respiratory depression

Cord around neck

Stuck in birth canal

Fast or excessively slow birth

Unknown/unsure

None

OTHER

Odd-shaped head

Does the child have any history of serious falls or injuries, including fractures, concussions, hospitalizations, etc.?

Yes No Unsure

Does the child wear a backpack?

Does child participate in sports or exercise activities?

Does child engage in any hobbies or activities which require prolonged, awkward or repetitive postures (violin, gymnastics, ballet, etc.)?

Yes No Unsure OTHER

Chemical Stressors

As an infant, was the child breastfed?

Was formula introduced?

Was cow's milk introduced?

Have solid foods been introduced?

Does the child have any food, liquid or juice intolerances or allergies?

Yes No Unsure OTHER

During the pregnancy, did the mother smoke?

Yes No Unsure

During the pregnancy, did the mother drink alcohol?

Yes No Unsure

During the pregnancy, did the mother use recreational drugs?

Yes No Unsure

Did the mother suffer any illnesses during the pregnancy?

Yes No Unsure OTHER

Were any nutritional supplements prescribed or taken during the pregnancy?

Yes No Unsure

Were ultrasound(s) performed during the pregnancy?

Yes No Unsure

Were any invasive procedures performed during the pregnancy (Amniocentesis, Cerclage, etc.)?

Yes No Unsure

Are there any pets in the child's home?

Yes No Unsure

Are there any smokers in the child's home or environment?

Yes No Unsure

Has the child had any adverse reactions to vaccinations or medicines?

Yes No Unsure

Is there any history of antibiotics given to the child?

Yes No Unsure

Psychosocial Stressors

Have there been any difficulties with child-parent bonding?

Yes No Unsure

Does the child have any behavioral problems?

Yes No Unsure

Have any of the following behaviors occurred? Check all that apply.

Attention issues

Night terrors

Bedwetting

Sleepwalking

Difficulty sleeping

Stutter or stammer

Failure to maintain eye contact

Unsure

Hearing issues

OTHER

Nervous tics

On average, how many hours per week of television does the child watch?

Do you feel the child’s social and emotional development is normal for their age?

Yes No Unsure

Was there any delay in terms of the child's achievement of developmental goals? Choose all that apply.

None, all developmental goals were met on schedule

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Employment Information

Regular Work Status:
Employer Name:
Employer Address:
Employer City:
Employer State:
Employer Zip:
Occupation:
Supervisor Name:
Supervisor Phone/Extension:
Physical Work Duties:

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What is the purpose of your visit?

Wellness Complaint Injury Other

Insurance & Payment for Care

How do you plan to pay for care?

Personal Insurance Third-Party Insurance No Insurance, Self-Pay

Name of Party Responsible for Payment:
Responsible Party Phone:

Primary Insurance

Secondary Insurance

Insurance Name:
Phone:
Address:
City:
State:
Zip:
ID/Policy #:
Group #:
Insured's Name:
Insured's Date of Birth:

Insurance Name:
Phone:
Address:
City:
State:
Zip:
ID/Policy #:
Group #:
Insured's Name:
Insured's Date of Birth:

If an auto accident, please provide:

Claim #:
Insurance Contact Person:
Insurance Phone:
Attorney's Full Name:
Attorney's Phone:

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Chiropractic Experience

Who referred you to our office?

Where did you hear about us?…

Please select all that apply.

Newspaper Sign Yellow Pages Community Event Mailing Other

Other:

Have you been adjusted by a chiropractor before?

Yes No

If yes…

What was the reason for those visits?

Doctor's Name:

Approximate date of last visit:

Has any member of your family ever seen a wellness chiropractor?

Yes No

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Reason for this Visit

Describe the reason for this visit

Please briefly describe, including the impact it has had on your life.

If you're only here for chiropractic wellness services please skip this section.

Wellness Sports Auto Fall Home Injury Job Chronic Discomfort Other

Briefly Explain:

When did this concern begin?

Has this concern:

Gotten Worse Stayed Constant Come and Gone

Does this concern interfere with:

Work Sleep Daily Routine Other Activities

Briefly Explain:

Has this concern occured before?

Yes No

Briefly Explain:

Have you seen other doctors for this concern?

Yes No

Doctor's Name:

Type of Treatment:

Results: Good Bad Indifferent

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For Women Only

COMPLETE THIS SECTION ONLY IF YOU ARE (OR THE PATIENT IS) A WOMAN OVER 16 YEARS OF AGE.

Are you pregnant?

No Yes

Are you nursing?

No Yes

Are you taking birth control?

No Yes

Do you experience painful periods?

No Yes

Do you have irregular cycles?

No Yes

Do you have breast implants?

No Yes

Do you perform a regular self breast examination?

No Yes

Do you take hormone replacement therapy (HRT)?

No Yes

Do you take oral contraceptives?

No Yes

Estimate the date of your most recent PAP/pelvic exam:

Date of last mammogram?

Date of Last Menstrual Period?

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Goals for Your Care

People see a chiropractor for a variety of reasons. Some go for relief of pain, some to correct the cause of pain and others for correction of whatever is malfunctioning in their body. Your doctor will weigh your needs and desires when recommending your care program. Please check the type of care desired so that we may be guided by your wishes whenever possible.

I want the Doctor to select the type of care appropriate for my condition.

Relief care: Symptomatic relief of pain or discomfort.
Corrective care: Correcting and relieving the cause of the problem as well as the symptom.
Comprehensive care: Bring whatever is malfunctioning in the body to the highest state of health possible with Chiropractic care.

Were You Aware That...

Doctors of Chiropractic work with the nervous system?

No Yes

The nervous system controls all bodily functions and systems?

No Yes

Chiropractic is the largest natural healing profession in the world?

No Yes

Health Problems & Concerns:

Please select all that you have had or currently have.

Other:

Have you had any of these Cardiovascular Diseases? Please select all that apply.

Myocardial infarction Hypertension Hypercholesterolemia Bypass surgery
Coronary artery disease

Do you have Diabetes? If so what type?

Type I Type II Juvenile

Do you have any stomach/digestive issues? Please select all that apply.

Ulcers Reflux IBS

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Authorization

I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.

* I agree with this statement of authorization

Name of the Insured: (Please Print)	_____________________________________________
Patient's/Guardian's signature:	_____________________________________________	Date:	__________

Signature

Finalizing Form

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Service provided by:

Patient Intake Form

Patient Information

Intensive Pediatric Evaluation

Draw Your Symptoms

Employment Information

Insurance & Payment for Care

Chiropractic Experience

Reason for this Visit

For Women Only

Goals for Your Care

Were You Aware That...

Health Problems & Concerns:

Authorization

Signature

Finalizing Form