All Family Chiropractic & Injury Clinic
4505 82nd St, Suite 9
Lubbock, TX 79424
806-785-7246

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.

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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.)

   

Draw Your Symptoms


Click on a crayon and draw on the body above to indicate your symptoms
Ache / Dull Sharp / Stabbing Numb / Tingling Pins & Needles Burning Throbbing Cramping Radiating Other Pains eraser eraser clear

How did you find out about our office?


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Employment Information


Current Symptoms


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Personal Health History


Family/Primary Physician

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Personal Incident History:


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Did you get professional care/treatment?

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Did you get professional care/treatment?

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Did you get professional care/treatment?

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Did you get professional care/treatment?

Social History & Life Choices:


 

Reason for this Visit

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

Does this concern interfere with:





Results:

Health Problems & Concerns:


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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. Dr. – patient relationship in chiropracticChiropractic It is important to acknowledge the differences between the health care specialties of chiropractic, osteopathy and medicine. Chiropractic care six to restore health through natural means and without the use of medicine or surgery. This approach to healthcare gives the human body maximum opportunity to utilize its inherent recuperative powers in the treatment process. The success of the chiropractic physician's procedures often depends on environment, underlying causes, physical and spinal conditions.Analysis Chiropractic physician conducts a clinical analysis for the express purpose of determining whether there is evidence of vertebral subluxation syndrome (VSS) or vertebral subluxation complexes ( VSC). When such a VSS and VSC complexes are found, chiropractic adjustments and ancillary procedures may be performed in an attempt to restore spinal integrity. It is the chiropractic premise the proper spinal alignment maximizes nerve transmission throughout the body and gives the body an opportunity to use its inherent recuperative powers. Due to the complexity of the human body, no physician can promise you specific results for chiropractic treatment. The results obtained from chiropractic adjustments depend upon the inherent recuperative powers of the patient's body.Diagnosis Although chiropractic physicians are experts in musculo-skeletal treatment and diagnosis, the VSS and VSC, they are not internal medicine specialists. Every chiropractic patient should be aware of his own symptoms and secure other opinions if he has any concerns as to the nature of his total condition. Your chiropractic physician may advise you to seek a second opinion from another professional, but you are responsible for the final decision on such matters.Informed consent for chiropractic care A patient seeking treatment from the chiropractic physician authorizes the chiropractic physician to care for the patient in accordance with the chiropractic treatment protocols. Chiropractic adjustments or other clinical procedures are usually beneficial and seldom cause any problems for the patient. In rare cases, underlying physical defects, deformities or pathologies may render the patient susceptible to injury. The chiropractic physician, of course, will not give a chiropractic adjustment or perform other procedures if he is aware of that such care may be harmful to the patient. It is the patients responsibility to disclose his health problems to the chiropractic physician, especially latent pathological defects, illnesses, or deformities which would otherwise not come to the chiropractic physician's attention. The patient should seek the treatment from the healthcare specialist who is qualified to provide the proper diagnostic and clinical procedures for the patients problems. The chiropractic physician is licensed to diagnose and treat musculo-skeletal problems and routinely works with healthcare providers from other disciplines to help provide prompt and effective care for his patients.Results The purpose of chiropractic services is to promote natural health through the reduction of the incidence of VSS or VSC in chiropractic patients. Since there are so many variables, it is difficult to protect the time schedule or if they can see you chiropractic treatment. Sometimes the patient's response to chiropractic treatment is immediate and phenomenal. In most cases there is more gradual but quite satisfactory response to chiropractic treatment. Occasionally the results obtained from chiropractic treatments are less beneficial to the patient than anticipated by both the chiropractic physician and the patient. Two or more similar conditions may respond differently to the same chiropractic care. Many patients who do not respond to medical care find quick relief from their symptoms through chiropractic treatment. Other conditions and countered by the patient responds better to medical care. The fact is that the side it's a chiropractic in medicine may never be so exact us to provide definite answers to all health problems. Both disciplines have made great strides in the diagnosis and treatment of health problems and will continue to improve the prognosis for patient care in the future.The patient should discuss any questions or problems with the doctor before the signing of the statement of policy.The undersigned acknowledges that he has read the foregoing statement and that he understands the nature of the care that he will receive from the chiropractic physician.

Name of the Insured:
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Patient's/Guardian's signature:
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Date:
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