Apex Chiropractic Center LTD
885 Spark Blvd
Ste 300
Sparks, NV 89434
775-359-1600

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.

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
Feet Inches
   
 

(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.)

   

Complaint Information


If you have more than one complaint, address your primary complaint in your responses to the questions in this section and select Yes to indicate that you have an additional complaint. The form will populate a secondary question section for you to address your additional complaint. You may address up to four complaints.

What is the purpose of your visit?
What is the reason for this visit?
Date of scheduled appointment
When did this condition begin?
How long have you had this condition?
What caused this condition?
Where is the discomfort?

Select only one area of discomfort for your chief complaint. Add additional areas of discomfort as additional complaints by selecting Yes in response to Do you have an additional complaint? at the bottom of this section.

Head

Neck

Back


Trunk

Upper Extremity






Lower Extremity





Does the discomfort radiate/travel?
Describe the quality of the discomfort. Choose all that apply.
Describe the onset of the discomfort. Choose only one.
Describe the intensity of the discomfort. Choose only one.
Rate the severity of your discomfort on a scale of 1-10 where 1 is the least severe and 10 is the most severe.
Least severe <----------------------------> Most severe
How often do you feel this discomfort? Choose only one.
How has this complaint changed since the onset?
What activity is most significantly affected by this discomfort?
What aggravates this condition? Choose all that apply.
What improves this condition? Choose all that apply.
What treatment have you received for this condition up to now?
Were any diagnostic tests performed to assess this condition (including X-rays, MRIs, etc.)?
Have you ever had any previous episodes of this condition?
In what ways does this condition affect your life and your ability to function? Choose all that apply.
Do you have an additional complaint?

Review of Systems


Musculoskeletal

Neurological

Head, Eyes, Ears, Nose and Throat

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Endocrine

Dermatological and Bleeding

Past, Family and Social History


List your (or the patient's) past surgical history. Choose all that apply and indicate the year in which the surgeries were performed.
Describe any past illnesses or conditions the doctor should be aware of and the age at which the illness(es) reportedly occurred. Respond respectively to each illness listed. If personal health history is good, select "No past illnesses (including diabetes, cancer, hypertension and progressive neurological diseases)"





List any past history of accidents or trauma. Choose all that apply.
Are you presently taking any medication?
List your (or the patient's) family health history. Choose all that apply to blood relatives only.
What are your (or are the patient's) current work habits? Choose all that apply.



How would you describe your (or the patient's) personal social habits? Choose all that apply.




How would you describe your (or the patient's) present exercise habits? Choose all that apply.
How would you describe your (or the patient's) diet and nutritional status? Choose all that apply.

Standard Pediatric Evaluation


Is there a history of any problems that the doctor should know about? Choose all that apply.
How was the baby delivered?
Were forceps used in the delivery process?
Was vacuum extraction used in the delivery process?
How many hours was the labor?
How long was the pushing (in minutes)?
Was this a single or multiple birth?
What was the birth weight (pounds)?
lbs.
What was the birth weight (ounces)?
oz.
What was the length of the child at birth (inches)?
inches in length
What was the total APGAR score (5 minutes after birth, 10 is perfect)?
At how many weeks was the child born (gestational age in weeks)?
 weeks
Which vaccines has the child had to date? Choose all that apply. If all vaccination are up to date, select "Received all childhood vaccinations."

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?
List any evidence of birth trauma:
Does the child have any history of serious falls or injuries, including fractures, concussions, hospitalizations, etc.?
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.)?
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?
During the pregnancy, did the mother smoke?
During the pregnancy, did the mother drink alcohol?
During the pregnancy, did the mother use recreational drugs?
Did the mother suffer any illnesses during the pregnancy?
Were any nutritional supplements prescribed or taken during the pregnancy?
Were ultrasound(s) performed during the pregnancy?
Were any invasive procedures performed during the pregnancy (Amniocentesis, Cerclage, etc.)?
Are there any pets in the child's home?
Are there any smokers in the child's home or environment?
Has the child had any adverse reactions to vaccinations or medicines?
Is there any history of antibiotics given to the child?
Psychosocial Stressors
Have there been any difficulties with child-parent bonding?
Does the child have any behavioral problems?
Have any of the following behaviors occurred? Check all that apply.
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?
Was there any delay in terms of the child's achievement of developmental goals? Choose all that apply.

For Men Only


COMPLETE THIS SECTION ONLY IF YOU ARE (OR THE PATIENT IS) A MAN OVER 16 YEARS OF AGE.
Do you have pain or lump in scrotum or testicles?
Do you have impaired libido (sex drive)?
Do you have discharge from your penis?
Do you have prostate problems?
Estimate the date of your most recent prostate exam:
Approximate Date:   
Estimate the date of your most recent PSA (Prostate-Specific Antigen) test:
Approximate Date:   
What was your PSA (Prostate-Specific Antigen) level on your latest test?

Employment Information


Insurance & Payment for Care


Primary Insurance
Secondary Insurance

If an auto accident, please provide:

Personal Health History


Family/Primary Physician

Separate details with "," comma as shown above.



Separate details with "," comma as shown above.

Separate details with "," comma as shown above.

Social History & Life Choices:


 

Chiropractic Experience

Please select all that apply.

Other:

If yes…

What was the reason for those visits?

Doctor's Name:

Approximate date of last visit:

For Women Only

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

Electronic Health Record (EHR) Information


Preferred Language: Ethnicity:
Race:
Smoking Status: Smoking Start Date:
Type of Tobacco:
Have you tried to quit? How much tobacco do you use?
How long have you used tobacco?
Current Medications And Dosage:
Medication Name Dosage
Medication Allergies:
Medication Name Reaction Date Discovered

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. ---------FINANCIAL POLICY: I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that this chiropractic office will prepare any necessary reports and forms to assist me in making collections from the insurance company and that any amount authorized to be paid directly to this office will be credited to my account upon receipt. I also give this office power of attorney to endorse checks made out to me, to be credited to my account. I also authorize my insurance company to make payment directly to this office. I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will be immediately due and payable. If this account is assigned for collection and/or suit, collection costs and/or interest, and/or attorney fees, and/or court costs will be added to the total amount due. I have read the office financial policy, and agree to abide by its terms.-----------AUTHORIZATION FOR TREATMENT, MEDICAL RELEASE, AND INFORMED CONSENT: I hereby request and consent to the performance of chiropractic adjustments and other procedures, including various physical therapy modalities and x-rays on me by the doctor of chiropractic and/or other licensed doctors of chiropractic who now or in the future treat me while employed by, working or associated with or serving as back-up for the doctor of chiropractic, whether signatories to this form or not. I have had an opportunity to discuss with the doctor of chiropractic and/or other office personnel the nature and purpose of chiropractic adjustments and procedures. I understand that results are not guaranteed. I understand and am informed that in the practice of chiropractic there are some risks to treatment, including, but not limited to, fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known, is in my best interests. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.---------- ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES: (Notice also posted on website- www.apexwellnessnv.com) I acknowledge that I have received, reviewed, understand and agree to the Notice of Privacy Practices of Apex Chiropractic Center, which describes the Practice’s Policies and procedures regarding the use and disclosure of any of my Protected Health Information created, received or maintained by the Practice---------.CONSENT FOR PURPOSES OF TREATMENT, PAYMENT, AND HEALTHCARE OPERATIONS: I consent to Apex Chiropractic Center’s (“the Practice’s”) use and disclosure of my Protected Health Information for the purpose of providing treatment to me, for purposes relating to the payment of services rendered to me, and for the Practice’s general healthcare operations purposes. Healthcare operations purposes shall include, but not be limited to, quality assessment activities, credentialing, business management and other general operation activities. I understand that the Practice’s diagnosis or treatment of me may be conditioned upon my consent as evidenced by my signature on this document.For purposes of this Consent, "Protected Health Information" means any information, including my demographic information, created or received by the Practice, that relates to my past, present, or future physical or mental health or condition; the provision of health care to me; or the past, present, or future payment for the provision of health care services to me; and that either identifies me or from which there is a reasonable basis to believe the information can be used to identify me. I understand I have the right to request a restriction on the use and disclosure of my Protected Health Information for the purposes of treatment, payment or healthcare operations of the Practice, but the Practice is not required to agree to these restrictions. However, if the Practice agrees to a restriction that I request, the restriction is binding on the Practice. I understand I have a right to review the Practice’s Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices describes my rights and the Practice’s duties regarding the types of uses and disclosures of my Protected Health Information. I have the right to revoke this consent, in writing, at any time, except to the extent that Physician or the Practice has acted in reliance on this consent.

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

Finalizing Form


  1. Submit Form!