Active Spinal & Sports Care
88 West 2nd Street
Morgan Hill, CA 95037
408-779-3565

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.)

   

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

Employment Information


Current Symptoms


If Yes, Explain:

If yes:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Where?




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.

Personal Incident History:


If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

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:

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.




Worker's Compensation







Describe the accident?

Do you lift from?

Do you have to reach?
Is your work area cluttered?
Do you push or pull?
Do you pick up or lift?

Do you lift in and out of a machine?
Type of Floor:

Type of ventilation:

Type of lighting:

Is your work area:

Do you have any other jobs?
Has outside help been hired?
Do you use a cart?



Auto Accident










Visited a Hospital or Doctor?






Were you rendered unconscious?
Traffic violation issued?
Retained an attorney?

In relation to the base of your skull, where was the headrest?

Impact to your vehicle came from?

The direction you were heading?
The direction they were heading?

The direction you were facing?
What did your vehicle impact?

Strike anything in the vehicle?

Describe the accident?

How did you feel right after?

Names of all persons in this accident:

Authorization

INSURANCE AUTHORIZATION I understand that my insurance for treatment may NOT cover Active Release Therapy or soft tissue work, which is necessary for the full and proper resolution of my condition. I agree that I am responsible for this portion of my care, which would be an additional $35 to my usual co-payment. LATE CANCELLATION/NO SHOW POLICY At Active Spinal & Sports Care, Inc. we emphasize quality Chiropractic and Healthcare services for our clients. Your well-being is important to us. Failure to provide our office with adequate notice of cancellation deprives another client from receiving care. If you wish to cancel or reschedule your appointment, we ask for at least 24 hours prior notification by phone in order to best assist those who may be in need of our services. Please note that our office charges at $45 fee for any missed appointments with less than 24 hours’ notice. ASSIGNMENT AND RELEASE I, the undersigned, assign directly to Active Spinal & Sports Care, Inc., Armen Agacanyan, DC, all insurance benefits, if any, otherwise payable to me for services rendered. I understand and agree that I am financially responsible for all charges for services rendered to me, whether or not paid by insurance and that payment is due at time of service. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered will immediately be due and payable. I clearly understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and me. I understand that the clinic does not promise that an insurance company will pay. Nor does the clinic promise that an insurance company should pay the fees as charged. I further understand that the clinic will not enter into a dispute with an insurance company for reimbursement or the amount of reimbursement. This is my obligation. I hereby authorize Active Spinal & Sports Care Inc. to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions and/or requests pertaining to my physical condition, including, but not limited to, all records, reports, progress notes, reports of diagnostic tests, x-rays and/or medical opinions. I certify to the best of my knowledge, the above information is complete and accurate. If the health plan information is not accurate, or if I am not eligible to receive a health care benefit through this provider, I understand that I am liable for all charges for services rendered and I agree to notify this doctor immediately whenever I have changes in my health condition or health plan coverage in the future. I understand that my chiropractor may need to contact my physician if my condition needs to be co-managed. Therefore I give authorization to my chiropractor to contact my physician, if necessary. INFORMED CONSENT I hereby request and consent to the performance of chiropractic adjustments and any other chiropractic procedures, including examination tests, diagnostic x-rays, and physical therapy techniques, for me (or the patient named below for which I am legally responsible) which are recommended by the doctor of chiropractic named below and/or other licensed doctors of chiropractic who now or in the future render treatment to me while employed by, associated with, or serving as back-up for Dr. Armen Agacanyan, DC, CCSP, DACRB. I understand that, as with any health care procedure, there are certain complications which may arise during a chiropractic adjustment, including but not limited to: muscle sprains and strains, disc injuries, dislocations, broken bones and costovertebral strains and separations. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. I do not expect the doctor to be able to anticipate all risks and complications and I wish to rely on the doctor to exercise judgment during the course of the procedure(s) which the doctor feels at the time, based on the facts then known, are in my best interest. I understand that chiropractic treatments are generally considered safe and effective. I have had an opportunity to discuss with the doctor named below and/or with office personnel the nature, purpose, and risks of chiropractic adjustments and other recommended procedures and have had my questions answered to my satisfaction. I understand that the results are not guaranteed. I have read (or have had read to me) the above explanation of the chiropractic adjustment and related treatment. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. By signing below I state that I have weighed the risks involved in undergoing treatment and have myself decided that it is in my best interest to undergo the chiropractic treatment recommended. Having been informed of the risks, I hereby give my consent to that treatment. 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. Armen B. Agacanyan, DC, CCSP, DACRB Active Spinal & Sports Care, Inc. 88 West Second StreetMorgan Hill, CA. 95037 408-779-3565 NOTICE OF PRIVACY PRACTICES This notice describes how medical information about you may be used and disclosed and how you can get access to this information. PLEASE REVIEW IT CAREFULLY. Active Spinal & Sports Care, Inc. is required, by law, to maintain the privacy and confidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information. Disclosure of Your Health Care Information Treatment: We may disclose your health care information to other healthcare professionals within our practice for the purpose of treatment, payment or healthcare operations. On occasion, it may be necessary to seek consultation regarding your condition from other health care providers associated with Active Spinal & Sports Care, Inc. It is our policy to provide a substitute health care provider, authorized by Active Spinal &Sports Care, Inc. to provide assessment and/or treatment to our patients, without advanced notice, in the event of your primary health care provider’s absence due to vacation, sickness, or other emergency situation. Payment: We may disclose your health information to your insurance provider for the purpose of payment or health care operations. As a courtesy to our patients, we will submit an itemized billing statement to your insurance carrier for the purpose of payment to Active Spinal & Sports Care, Inc. for health care services rendered. If you pay for your health care services personally, we will, as a courtesy, provide an itemized billing to your insurance carrier for the purpose of reimbursement to you. The billing statement contains medical information, including diagnosis, date of injury or condition, and codes which describe the health care services received. Workers’ Compensation: We may disclose your health information as necessary to comply with State Workers’ Compensation Laws. Emergencies: We may disclose your health information to notify or assist in notifying a family member, or another person responsible for your care about your medical condition or in the event of an emergency or of your death. Public Health: As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability, reporting child abuse or neglect, reporting domestic violence, reporting to the Food and Drug Administration problems with products and reactions to medications, and reporting disease or infection exposure. Judicial and Administrative Proceedings: We may disclose your health information in the course of any administrative or judicial proceeding. Law Enforcement: We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena, and other law enforcement purposes. Deceased Persons: We may disclose your health information to coroners or medical examiners. Public Safety: It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public. Courtesy Calls to Your Residence: As a courtesy to our patients, it is our policy to send a text, email, or call your home 1-3 days prior to your scheduled appointment to remind you of your appointment time. If you are not at home, we leave a reminder message on your answering machine or with the person answering the phone. No personal health information will be disclosed during this recording or message other than the date and time of your scheduled appointment along with a request to call our office if you need to cancel or reschedule your appointment. Change of Ownership: In the event that Active Spinal & Sports Care, Inc. is sold or merged with another organization, your health information/record will become the property of the new owner. Your Health Information Rights: You have the right to request restrictions on certain uses and disclosures of your health information. Please be advised, however, that Active Spinal & Sports Care, Inc. is not required to agree to the restriction that you requested. You have the right to have your health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication or delivery, upon your request. You have the right to inspect and copy your health information. You have a right to request that Active Spinal & Sports Care, Inc. amend your protected health information. Please be advised, however, that Active Spinal & Sports Care, Inc. is not required to agree to amend your protected health information. If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s) and information about how you can disagree with the denial. You have a right to receive an accounting of disclosures of your protected health information made by Active Spinal & Sports Care, Inc. You have a right to a paper copy of this Notice of Privacy Practices at any time upon request. Changes to this Notice of Privacy Practices: Active Spinal & Sports Care, Inc. reserves the right to amend this Notice of Privacy Practices at any time in the future, and will make the new provisions effective for all information that it maintains. Until such amendment is made, Active Spinal & Sports Care, Inc. is required by law to comply with this Notice. Active Spinal & Sports Care, Inc. is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about your privacy rights, please contact: Armen Agacanyan by calling this office at 408-779-3565. If Armen Agacanyan is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days. Complaints: Complaints about your Privacy rights, or how Active Spinal & Sports Care, Inc. has handled your health information should be directed to Armen Agacanyan by calling this office at 408-779-3565. If Armen Agacanyan is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days. If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to: DHHS, Office of Civil Rights, 200 Independence Avenue S.W. Room 509F HHH BuildingWashington, DC 20201 This notice is effective as of 4/3/17. I have read the Privacy Notice and understand my rights contained in the notice. By way of my signature, I provide Active Spinal & Sports Care, Inc. with my authorization and consent to use and disclosed my protected health care information for the purposes of treatment, payment and health care operations as described in the Privacy Notice.

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

Signature


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