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
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Contact Information
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(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.)
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Draw Your Symptoms
Click on a crayon and draw on the body above to indicate your symptoms
Current Symptoms
If Yes, Explain:
If yes:
If Yes, Explain:
If Yes, Explain:
If Yes, Explain:
If Yes, Explain:
If Yes, Where?
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.
Personal Incident History:
Family Health History
Separate details with "," comma as shown above.
(Example: arthritis, cancer, diabetes, heart disease, kidney disease, high cholesterol,
etc.)
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:
Reason for this Visit
If you're only here for chiropractic wellness services please skip this section.
Does this concern interfere with:
Results:
For Women Only
COMPLETE THIS SECTION ONLY IF YOU ARE (OR THE PATIENT IS) A WOMAN OVER 16 YEARS OF AGE.
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.
Were You Aware That...
Health Problems & Concerns:
Please select all that you have had or currently have.
Authorization
The Department of Health and Human Services has established a “Privacy Rule” to help insure that personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patients’ consent for uses and disclosures of health information about the patient to carry out treatment, payment, or health care operations. As our patient we want you to know that we respect the privacy or your personal medical records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide the minimum necessary information to only those we feel are in need of your health care information and information about treatment, payment, or health care operations, in order to provide health care that is in your best interest. We also want you to know that we support your full access to your personal medical records. We may have indirect treatment relationships with you (such as laboratories that only interact with physicians and not patients), and may have to disclose personal health information for purposes of treatment, payment, or health care operations. These entities are most often not required to obtain patient consent. Furthermore it may be necessary for us to electronically record, change, and access medications, laboratory findings and radiology/imaging. You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or a previously signed consent. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer. You have to right to review our privacy notice, to request restrictions and revoke consent in writing after you have reviewed our privacy notice.
Name of the Insured:
(Please Print)
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_____________________________________________
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Patient's/Guardian's signature:
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_____________________________________________
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Date:
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__________
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Signature