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
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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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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.
Mechanism of Injury
The injury was due to: (choose one)
What date did the accident happen?
FOR WORKMAN'S COMPENSATION-RELATED VISITS ONLY: How did the injury occur? Choose all that apply.
As a pedestrian, what were you (or was the patient) doing at the time of the accident?
Where were you (or was the patient) looking at the time of impact?
Did you (or the patient) receive an injury to the head?
Did your (or the patient) lose consciousness?
What part of your (or the patient’s) vehicle was impacted? Choose all that apply.
In what direction was your (or the patient's) vehicle moving?
What was the estimated speed of your (or the patient’s) vehicle?
What was the extent of the damage to your (or the patient's) vehicle?
What was the extent of the damage to the other vehicle?
In what direction was the other vehicle moving?
What was the estimated speed of the other vehicle?
Was your (or the patient’s) vehicle towed from the scene?
Did police arrive at the scene?
Was an accident report taken?
Did Emergency Medical Services arrive at the scene?
Were you (or was the patient) transported to a medical facility (ER or hospital)?
Have you (or has the patient) received any treatment since the accident?
What was the location of symptoms felt at the time of the accident? Choose all that apply.
Head
Neck
Back
Trunk
Upper Extremity
Lower Extremity
Describe the discomfort felt at the time of the accident. Choose all that apply.
Are there any additional symptoms which appeared since the accident happened? Choose all that apply.
Describe the status of your symptoms since the accident. Choose all that apply.
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?
Which of the following medications are you presently taking? Choose all that apply.
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.
Draw Your Symptoms
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Click on a crayon and draw on the body above to indicate your symptoms
Employment Information
Insurance & Payment for Care
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Primary Insurance
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Secondary Insurance
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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.
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.
Electronic Health Record (EHR) Information
Authorization
Informed Consent to Care: A patient coming to the doctor gives him/her permission and authority to care for them in accordance with appropriate tests, diagnosis, and analysis. The clinical procedures performed are usually beneficial and seldom cause any problem. In rare cases, underlying physical defects, deformities or pathologies may render the patient susceptible for injury. The doctor, of course, will not provide specific healthcare, if he/she is aware that such care may be contraindicated. It is the responsibility of the patient to make it known or to learn through health care procedures from whatever he/she is suffering from: latent pathological defects, illnesses, or deformities, which would otherwise not come to the attention of the physician. I agree to settle any claim or dispute I may make against or with any of these persons or entities, whether related to the prescribed care or otherwise, will be resolved by binding arbitration under the current malpractice terms which can be obtained by written request. PHYSICIAN NETWORK AUTHORIZATION/CONSENT FORM GENERAL AUTHORIZATION FOR TREATMENT/CONTACT I authorize physicians, nurse practitioners, and/or physician assistants of Collaborative Healthcare who may attend me, their assistants, including those employed by Collaborative Healthcare to provide the medical care, tests, procedures, drugs, blood and blood products, services, and supplies considered advisable by my provider. These services may include pathology, radiology, emergency services and other special services ordered by my provider. In consenting to treatment, I have not relied on any statements as to results. I further authorize my provider to examine, use, store, and/or dispose of in any manner (except for organ donation and/or transplantation) any tissue, fluids or parts removed from my body. In the event that any personnel assisting in the provision of care and treatment suffer inadvertent exposure to any of my blood and/or other bodily substances that are capable of transmitting disease and I am unable to consult in timely with my physician prior to testing, I consent to limited testing to determine presence, if any, of antibodies to hepatitis A, B, and C and HIV. I authorize Collaborative Healthcare to contact me on any phone number provided by me for the purposes of conducting business with me or contacting me concerning my account. I consent to the use of automated dialers for that purpose. This authorization form permits: Collaborative Healthcare – 716 Old Cherokee Rd – Lexington, SC 29072 to use or disclose protected health information listed in the description section below for the above patient.Entity or person to receive the information: The PatientDescription of information to be used or disclosed: Unencrypted email / text communications to give you information about treatment alternatives, or other health related benefits, events or services. If you do not wish to receive the information about treatment alternatives, other health related benefits, events or services, you may notify our office in writing (Emails/text NOT accepted) and you will receive no further information.Purpose of use or disclosure: To inform patients of healthcare options, surveys or events. There will be NO remuneration or financial payment made to our facility for making these communications.Expiration date or event:This authorization shall be enforced until revoked by the patient by notifying our office in writing (Emails/text NOT accepted).Rights of the Patient:I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing. I understand that I have the right to revoke this authorization at any time by sending a written notification to the address listed at the top of this form I understand that a revocation is not effective in cases where the information has already been used or disclosed but will be effective going forward. I understand that information used or disclosed as a result of this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law. RELEASE AND ASSIGNMENT OF BENEFITSI understand that payment is due at the time service is rendered. I hereby authorize the release of any medical information to (1) an insurance company through which I claim benefits and (2) any physician involved in my medical care. I realize the authorization allows Collaborative Healthcare to release any information to any of my insurers or physicians. I authorize and direct my insurers to pay directly to Collaborative Healthcare and/or its physicians/providers any and all benefits up to the amount of my bill pertaining to all charges incurred. I assign to Collaborative Healthcare, including its affiliates, any and all benefits or proceeds, of any type whatsoever, to which I am entitled, with respect to the health care service(s) I receive, including but not limited to, the proceeds of any liability settlement or judgment being paid by or on behalf of a third-party and any benefits due from any third-party insurance policy. I direct that all such benefits be paid directly to Collaborative Healthcare and/or its affiliates, including its physician/providers, and applied to my account(s) until the account(s) is paid in full. I understand that I am personally responsible for any remaining fees. I hereby agree to pay all costs and reasonable attorney fees in the even this account is turned over to an attorney and/or collection agency for collection. ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICESI hereby acknowledge that I have received the Notice of Privacy Practices for Collaborative Healthcare.I agree that a photo static copy of this agreement shall serve as the original.
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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