Chiropractic Connection PC
709 Co. Rd 75 W
St. Joseph, MN 56374-8660
(320) 363-4694

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

Current Symptoms


If Yes, Explain:

If yes:

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If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Where?




Personal Health History


Family/Primary Physician

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Family Health History


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(Example: arthritis, cancer, diabetes, heart disease, kidney disease, high cholesterol, etc.)

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

Chiropractic Consent: When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both of us to be working for the same subjective. It is important that each patient understand both the objective(s) and the method(s) that will be used to attain this subjective.You have the right, as the patient, to be informed about the condition and the recommended care to be provided so that you make the decision whether or not to undergo chiropractic care after being advised of the known benefits, risks, and alternatives. One disturbance to the nervous system is called a vertebral subluxation. This occurs when one or more of the 24 vertebra in the spinal column become misaligned and/or do not move properly. This causes and unhealthy change to nerve function and interference to the nervous system. This may result in pain and dysfunction or may be entirely asymptomatic. Subluxations are corrected and/or reduced by a chiropractic adjustment. An adjustment is the specific application of force to correct and/or reduce vertebral subluxation. Our chiropractic method of correction is by specific adjustments to the spine. Chiropractic Care has been proven to be very safe and effective. It is not unusual however, to be sore after your first few adjustments. Although rare it is possible to suffer from other side effects; i.e. muscle spasms, stiffness, rib fracture, headache, dizziness and stroke.HIPPA: I was informed that I may obtain a copy of the HIPPA Privacy Procedure. You have the right to revoke or make changes, in writing, to this authorization at any time. Please ask one of the staff members for assistance in this matter.I certify that I am the patient or legal guardian listed on the form. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent the collection and use of the above information for use within this office of chiropractic.

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

Signature


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