Copper Canyon Chiropractic
1650 North Dysart Road
Suite #1
Goodyear, AZ 85395
623-925-9045

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

Employment Information


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.

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?



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

I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.HIPAA Notice of Privacy PracticesTHIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED ANDHOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY.Our ObligationsWe are required by law to:! • Maintain the privacy of protected health information! • Give you the notice of your legal duties and privacy practices regarding health information about you! • Follow the terms of our notice that is currently in effectHow We May Use and Disclose Health InformationDescribed as follows are the ways we may use and disclose health information that identifies you (“HealthInformation”). Except for the following purposes,we will use and disclose health information only with your written permission. You may revoke such permissions atany time by writing to our practice'sprivacy officer.Treatment. We may use and disclose Health Information for your treatment and to provide you with treatment-relatedhealth care services. For example, we may disclose Health Information to doctors, nurses, technicians, or otherpersonnel, including people outside our office, who are involved in your medical care and need the information toprovide you with medical care.Payment. We may use and disclose Health Information so that we or others may bill and receive payment from you,an insurance company, or a third party for treatment and services you receive. For example, we may give your healthplan information so that they will pay for your treatment.Health Care Operations. We may use and disclose Health Information for health care operation purposes. Theseuses and disclosures are necessary to make sure that all of our patients receive quality care to operate and manageour office. For example, we may use and disclose information to make sure the obstetric or gynecologic care youreceive is of the highest quality. We also may share information with our entities that have a relationship with you (forexample, your health plan) for their health care operation activities.Appointment Reminders, Treatment Alternatives, and Health Related Benefits and Services. We may use anddisclose Health Information to contact you and remind you that you have an appointment with us. We also may useand disclose Health Information to tell you about treatment alternatives or healthrelated benefits and services that may be of interest to you.Individuals Involved in Your Care or Payment for Your Care. When appropriate, we may share Health Informationwith a person who is involved in your medical care or payment for your care, such as your family or a close friend. Wealso may notify your family about your location or general condition or disclose such information to an entity assistingin a disaster relief effort.Research. Under certain circumstances, we may use and disclose Health Information for research. For example, aresearch project may involve comparing the health of patients who receive one treatment to those who receiveanother for the same condition. Before we use or disclose Health Information for research, the project will go througha special approval process. Even without special approval, we may permit researchers to look at records to help themidentify patients who may be included in their research project or for other similar purposes.Special Situations As required by law. We will disclose Health Information when required to do so by international, federal, state, or local law.To Avert a Serious Threat to Health of Safety. We will disclose Health Information when necessary to preventa serious threat to your health and safety or the public, or another person. Disclosure, however, will be madeonly to someone who may be able to help provide treatment.Business Associates. We may disclose Health Information to our business associates that perform functions on ourbehalf or to provide us with services if the information is necessary for such functions or services. For example, wemay use another company to perform billing services on our behalf. All of our business associates are obligated toprotect the privacy of your information and are not allowed to use or disclose any information other than that asspecific in our contract.Organ and Tissue Donation. If you are an organ donor, we may use or release Health Information to organizationsthat handle organ procurement or other entities engaged in procurement; banking or transportation of organs, eyes,or tissues to facilitate organ, eye, or tissue donation, and transplantation.Military and Veterans. If you are a member of the army forces, we may use or release Health Information asrequired by military command authorities. We also may release Health Information to the appropriate foreign militaryauthority if you are a member of a foreign military.Worker's Compensation. We may release Health Information for worker's compensation or similar programs. Theseprograms provide benefits for work-related injuries or illness.Public Health Risks. We may disclose Health Information for public health activities. These activities generallyinclude disclosure to prevent or control disease, injury, or disability; report child abuse or neglect; report reactions tomedications or problems with products; notify people of recalls of products they may be using; inform a person whomay have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and reportto the appropriate government authority if we believe a patient has been a victim of abuse, neglect, or domesticviolence. We will only make this disclosure if you agree or when required by law.Health Oversight Activities. We may disclose Health Information to a health oversight agency for activitiesauthorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure.These activities are necessary for the government to monitor the health care system, government programs, andcompliance with civil rights laws.Lawsuits and Disputes. If you are involved in a lawsuit of a dispute, we may disclose Health Information in responseto a court or a court administrator order. We also may disclose Health Information in response to a subpoena,discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have beenmade to tell you about the request or to obtain an order protecting the information requested.Law Enforcement. We may release Health Information if asked by a law enforcement official if the information is: 1)in response to a court order, subpoena, warrant, summons, or similar process; 2) limited information to identify orlocate a suspect, fugitive, material witness, or missing person; 3) about the victim of crime even if, under certaincircumstances, we are unable to obtain the person's agreement; 4) about a death we believe may be the result ofcriminal conduct; 5) about criminal conduct on our premises and; 6)in an emergency to report a crime to the locationof the crime if victims, or the identity, description, or location of the person who committed the crime.Coroners, Medical Examiners, Funeral Directors. We may release Health Information to a coroner or medicalexaminer. This may be necessary, for example, to identify a deceased person or determine the cause of death. Wemay also release Health Information to funeral directors as necessary for their duties.National Security and Intelligence Activities. We may release Health Information to authorized federal officials sothey may provide protection to the President, other authorized persons, or foreign heads of state, or to conductspecial investigations.Protective Services and Intelligence Activities. We may release Health Information to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state, or to conductspecial investigations. Inmates or Individuals in Custody. If you are an inmate of a correctional institution or other custody of a lawenforcement official, we may release Health Information to the correctional institution or law enforcement official. Thisrelease would be made if necessary 1) for the institution to provide you with health care; 2) to protect your health andsafety or the health and safety of others, or; 3) for the safety and security of the correctional institution.Your RightsYou have the following rights regarding Health Information we have about you:Right to Inspect and Copy. You have the right to inspect and copy Health Information that we may used to makedecisions about your care or payment for your care. This includes medical and billing records, other thanpsychotherapy notes. To inspect and copy this information, you must make your request in writing, to our PrivacyOfficer.Right to Amend. If you feel that Health Information we have is incorrect or incomplete, you may ask us to amend theinformation. You have the right to request an amendment for as long as the information is kept by or for our office. Torequest an amendment, you must make your request, in writing, to our Privacy Officer.Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures we made ofHealth Information for purposes other than treatment, payment, and health care operations or for which you providedwritten authorization. To request an accounting of disclosures, you must make your request, in writing, to our PrivacyOfficer.Right to Request Restrictions. You have the right to request a restriction or limitation on the Health Information weuse or disclose for treatment, payment, or health care operation. You also have a right to request a limit on the HealthInformation we disclose to someone involved in your care or the payment for your care, like a family member orfriend. For example, you can ask that we not share information about your particular diagnosis or treatment with yourspouse. To request a restriction, you must make your request, in writing, to our Privacy Officer. We are not requiredto agree with your request. If we agree, we will comply with your request unless the information is needed toprovide you with emergency treatment.Right to Request Confidential Communication. You have the right to request that we communicate with you aboutyour medical matters in a certain way or at a certain location. For example, you can ask that we contact you only bymail or at work. To request confidential communications, you must make your request, in writing, to our PrivacyOfficer. Your request must specify how or where you wish to be contacted. We will accommodate reasonablerequests.Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You must ask us to give youa copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to apaper copy of this notice. You may obtain a copy of this notice by contacting ouroffice.Changes to This NoticeWe reserve the right to change this notice and make the new notice apply to Health Information we already have aswell as any information we receive in the future. We will post a current copy of our notice at our office. The notice willcontain the effective date on the first page, in the top right hand corner.ComplaintsIf you believe your privacy has been violated, you may file a complaint with our office or with the Secretary of theDepartment of Health and Human Services. To file a complaint with our office, contact our Privacy Officer. Allcomplaints must be made in writing. You will not be penalized for filing a complaint.By Subscribing my name below, I acknowledge receipt of a copy of this notice, and my understanding and myagreement to its terms.INFORMED CONSENT TO CHIROPRACTIC ADJUSTMENTS AND CAREI hereby request and consent to the performance of chiropractic adjustments and otherchiropractic procedures, including various modes of physical therapy and diagnostic xrays,on me (or the patient named below, for whom I am legally responsible) by thedoctor of chiropractic named below and/or other licensed doctors of chiropractic whonow or in the future treat me while employed by, working or associated with or servingas back-up for the doctor of chiropractic named below, including those working at theclinic or office listed below or any other office or clinic.I have had the opportunity to discuss with the doctor of chiropractic named below and/orwith other office or clinic personnel the nature and purpose of chiropractic adjustmentsand other procedures.I understand and I am informed that, as in the practice of medicine, in the practice ofchiropractic there are some risks to treatment, including, but not limited to, fractures, discinjuries, strokes, dislocations and sprains. I do not expect the doctor to be able toanticipate and explain all risks and complications, and I wish to rely on the doctor toexercise judgment during the course of the procedure which the doctor feels at the time,based upon the facts known, is my best interest.I have read, and or have had read to me, the above consent. I have also had anopportunity to ask questions about its content, and by signing below I agree to theabove-named procedures. I intend this consent form to cover the entire course oftreatment for my present condition and for any future condition (s) for which I seektreatment.

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

Signature


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