Auburn Chiropractic Health Clinic, Inc.
861 N. Dean Rd., Ste. A
Auburn, Alabama 36830
(334) 501-4691

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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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.

Yes, surgical history

No surgical history

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)"

Yes, past illnesses

No past illnesses (including diabetes, cancer, hypertension and progressive neurological diseases)

Number of children:

Number of pregnancies:

Number of deliveries

List any past history of accidents or trauma. Choose all that apply.

No previous trauma reported

Multiple boating accidents

No new trauma reported since initial intake

Resulting in fracture(s)

Single automobile accident

Resulting in permanent injury or disability

Multiple automobile accidents

Resulting in hospitalization(s)

Slip and fall

Resulting in no significant injury or loss

Multiple slip and falls

Resulting in sprains/strains

Single motorcycle accident

Resulting in loss of consciousness

Multiple motorcycles accident

Suicide (including attempts)

Single boating accident

OTHER

Are you presently taking any medication?

Yes No

List your (or the patient's) family health history. Choose all that apply to blood relatives only.

No family history of diabetes, cancer, hypertension and progressive neurological disorders.

Not applicable, patient was adopted

Extremity issues

Unknown

Fracture

No change in family health history

Heart disease

AIDS/HIV

Hepatitis

Alcoholism

Hereditary disorder

Alzheimer's

Hernia

Anemia

Herniated disc

Anorexia

High blood pressure

Arthritis

High cholesterol

Asthma

Hospitalization

Bleeding disorders

Kidney disease

Breast lump

Liver disease

Bronchitis

Migraine headaches

Bulimia

Miscarriage

Cancer

Multiple sclerosis

Chemical dependency

Natural labor

Congenital anomaly

Neuromuscular issues

Depression

Osteoarthritis

Diabetes

Trauma/injury

Emphysema

OTHER

Epilepsy

What are your (or are the patient's) current work habits? Choose all that apply.

None reported

Permanently fully disabled

No change in work habits since condition began

Permanently partially disabled

Cannot not work due to presenting condition

Full-time

Retired

Part-time

Student

Homemaker

Unemployed

0 to 20 hours per week

50 to 60 hours per week

20 to 40 hours per week

60 to 70 hours per week

40 to 50 hours per week

Over 70 hours per week

Mostly sitting

Computer

Mostly standing

Repetitive

Mostly walking

Telephone

Light labor

Difficult

Moderate labor

Enjoyable

Heavy labor

Relaxed

Sedentary

Stressful

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

No change in social habits since injury

A social drinker

Does not smoke, drink alcohol or take recreational drugs

Current every day smoker

Light tobacco smoker

Current some day smoker

Never smoked tobacco

Ex-smoker

Smoker, current status unknown

Heavy tobacco smoker

Unknown if ever smoked

A light drinker

An alcoholic

A moderate drinker

A recovering alcoholic

A heavy drinker

Does not drink caffeine

Drinks 2 to 4 cups of caffeine per day

Drinks 1 cup of caffeine in the morning

Drinks 5 or more cups of caffeine per day

Does not use recreational drugs

Heavy use of recreational drugs

Light use of recreational drugs

Is drug addicted

Moderate use of recreational drugs

Is A recovering drug addict

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

No changes in exercise habits since condition began

Daily

Mountain climbing

None

Ping-Pong

Every other day

Racquetball

Few times a week

Running

Once a week

Skiing

Almost nothing

Skydiving

Aerobic

Snowboarding

Stretching

Soccer

Strength

Surfing

Baseball

Tennis

Basketball

Volleyball

Blading

Walking

Boating

Waterskiing

Climbing

Weight training

Cycling

Weight training with a personal trainer

Football

Pilates

Golf

Spinning

Handball

Step

Hang gliding

Yoga

Hiking

Zumba

Ice skating

OTHER

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

No changes in diet or nutrition since condition began

Controlled

Atkins

Out-of-control

Diabetic

Restricted

Gluten free

Unrestricted

Ideal Protein

1 to 2 meals a day

Jenny Craig

2 to 3 meals a day

Kosher

More than 3 meals a day

Macrobiotic

Reports eating too little

Paleo

Reports eating too much

Raw food

Binges

South Beach

Purges

Vegan

Balanced

Vegetarian

High protein

Weight Watchers

Low carbohydrate

Zone

Low-fat

Does not take daily supplements

Low-cholesterol

Takes daily supplements

No red meat

OTHER

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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

Current Symptoms

Where did the injury occur?

Automobile Work 3rd Party Premises Other

Date of Injury:

Please Describe how the injury, pain, or discomfort originated:

Please describe your pain/discomfort:

Select frequency you experience pain from this condition:

Always Hourly Daily Occasionally

Does this condition interfere with any of your daily activities or routines?

No Yes

Has this condition affected your quality of sleep or ability to sleep?

No Yes

Has this condition affected your appetite?

No Yes

If Yes, Explain:

Have you missed any work due to this injury?

No Yes

If yes:
Select unable to work from date:
Select day you have or will return to work:

Have you reduced or limited your work hours because of this condition?

No Yes

If Yes, Explain:

Is the pain/discomfort worse at certain times of the day?

No Yes

If Yes, Explain:

Does the weather affect your pain/discomfort?

No Yes

If Yes, Explain:

List anything that aggravates your condition:

List anything that relieves or improves your condition:

Have you received professional treatment for this condition?

No Yes

If Yes, Explain:

Have you had X-rays taken for this condition?

No Yes

If Yes, Where?

Pain level Rating - Scale 1 to 10 (Where 1 is least pain and 10 is maximum pain)

At its best: At its Worst: Current Level:

Have you ever had this same condition?

No Yes

If Yes, When?:

List other practitioners seen for this injury/condition:

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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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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

Past, Family and Social History

Draw Your Symptoms

Employment Information

Current Symptoms

Insurance & Payment for Care

Chiropractic Experience

Reason for this Visit

Authorization

Signature

Finalizing Form