Back In Balance Chiropractic
507 NW 60Th Street Suite A
Gainesville, FL 32607-6027
(352) 271-1211

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?

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

Insurance & Payment for Care


Primary Insurance
Secondary Insurance

If an auto accident, please provide:

For Women Only

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

Authorization

Patient Health Information and Privacy Policy This policy outlines the way Patient Health Information (PHI) will be used in this office and the patient’s rights concerning those records. You must read and consent to this policy before receiving services. A complete copy of the Health Information Portability and Accountability Act (HIPPAA) is available at our front desk. 1.The Patient understands and agrees to allow this office to use their PHI for the purpose of treatment, payment, health care operations and coordination of care. The patient agrees to allow this office to submit requested PHI to the payor(s) named by the patient for the purpose of payment. This office will limit the release of all PHI to the minimum necessary to receive payment. 2.The patient has the right to examine and obtain a copy of their health records at any time and request corrections. The patient may request to know what disclosures have been made, and submit in writing any further restrictions on the use of their PHI. This office is not obligated to agree to those restrictions. 3.The patient’s written consent shall remain in effect for as long as the patient receives care at this office, regardless of the passage of time, unless the patient provides written notice to revoke their consent. A revocation of consent will not apply to any prior care or services. 4.This office is committed to protecting your PHI and meeting its HIPPAA obligations: Staff have been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures. 5. Patients have the right to file a formal complaint with our privacy official about any suspected violations. 6.This office has the right to refuse treatment if the patient does not accept the terms of this policy. Consent to Professional Treatment I certify that all information provided to this practice is true and correct, to the best of my knowledge. I hereby give consent to this practice and its health care providers, consultants, assistants or designees to render care and treatment to me as they deem necessary. I recognize that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made as to the result of evaluation and treatment. If the patient is a minor child, under the age of eighteen (18) at the date of treatment, I hereby stipulate that I am the legal guardian of the child, and grant my consent for the treatment of the child as provided for herein. I acknowledge that may refuse treatment at any time. Assignment of Benefits and Release of Records I hereby assign to this practice all of my medical and procedure benefits to which I am entitled, including major medical benefits. I hereby authorize and direct my insurance carrier(s) including medicare and other government sponsored programs if applicable, private insurance and any other health care plans to issue payment directly to this practice for medical services rendered. This assignment is irrevocable I hereby authorize this practice to release any medical or other information requested by third party payors, including government agencies, insurance carriers, or any other entities necessary to determine insurance benefits or benefits payable for related services and supplies provided to me by the practice. Financial Obligation I hereby accept full financial responsibility for services rendered by this practice. I accept full responsibility for any fees incurred, regardless of insurance coverage. I understand that my insurance carrier may not approve or reimburse my medical services in full due to usual and customary rates, benefit exclusions, coverage limits, lack of authorization, or medical necessity. I further understand that I am responsible for fees not paying in full, co-payments, and policy deductibles and co-insurance except where my liability is limited by contract or state or federal law. Income cases, exact insurance benefits cannot be determined until the insurance company receives the claim. Should the account be referred to an attorney or collection agency for collection, I shall pay all fees, including but not limited to legal fees, collection agency fees, and any and all other expense incurred in the collection of past due accounts. It is my responsibility to notify this practice of any changes to my health care coverage. You may direct any questions regarding this financial obligation to the clinic manager or physician. Cancellation Policy Our goal is to provide quality healthcare at a good price. We are unlike other chiropractic offices in that our visits are longer and we do not book multiple patients for each time slot. The time you have scheduled is reserved only for you. This commitment is not without cost. Our policy for charging for missed appointments not cancelled or rescheduled within a reasonable time is as follows: $30 fee for every 10 minutes of your appointment $45 fee for any massage or exercise therapy appointment Any appointment over 10 minutes in length requires 48 hours notice, 10 minute appointments require 24 hour notice. If extenuous circumstances beyond your control prevent you from cancelling your appointment within a timely manner, please feel free to request your account to be credited charges incurred. It is not our intention to apply this policy unfairly, but to encourage patients to help us provide quality care in a timely manner.

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

Signature


Finalizing Form


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