Complete Care Chiropractic and Wellness Clinic
30061 Schoenherr Rd. Ste B
Warren, MI 48088
Ph: 586-576-0701

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.

How did you find out about our office?


Did you hear about our office from an advertisement?

If Yes, Where:

Did you hear about our office from a phone or professional directory?

If Yes, Where:

Authorization

Please review the following consents/policies in our office. These documents are also available in hard copy upon your first visit or in the lobby. Informed Consent/Clinical Release of Records: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. We do not offer to diagnose or treat any condition other than vertebral subluxations and what is in our Scope of Practice. However if during the course of an evaluation, we encounter non-chiropractic findings we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend you seek a specialist in that field. As with all health services there may be risks involved but please rest assure that all precautionary measures, diagnostic tests and orthopedic testing will be done and with consent performed to minimize any risks. By signing below you are authorizing treatment and understanding the information above. Our doctors are more than happy to discuss any risks or concerns about treatment on your first visit. Your signature also allows us our office release any information offered above regarding your Personal Health Information or request any records/imaging from any other facility to help ensure the proper treatment and care. By signing below you understasnt this is not a medical diagnostic center but a chiropractic & wellness clinic in which the mail focus is to correct spinal subluxations and to reduce pain and improve quality of life so you can function better. Our staff does not diagnose sever illnesses, disease or any physical or mental conditoin, nor do we prescribe medication. Notice of HIPAA /Patient Privacy:Protecting the privacy of your personal health information (PHI) is important to us. Disclosure of your protected health information without authorization is strictly limited to defined situations that include emergency care, quality insurance activities, public health, research and law enforcement situations. Any other disclosure for the purposes of treatment, payment or practice operations will be made only after obtaining your consent. You may request copies of your records that will be made available within 14 days of your request. With our new program, we may contact you for appointment reminders, announcements and inform you about our practice. If you do not want to receive these communications from our clinic please see our Patient Care Co-ordinator to opt-out. I understand that, under the Health Insurance Portability & Accountablity Act I have certain rights to my privacy regarding my private health information. I understand this information can be used to conduct, plan and direct my treatment and the clinic may follow up with multiple providers that may be treating me. The complete HIPAA manual is in the waiting room for my review and a hard copy is available at the front desk for you to take home for review. I have read and understand your notice of Privacy Practices. Patient-Provider Partnership Agreement:As a clinical Practice within a Patient Centered Medical Home-Neighborhood we are committed to your life-long health and wellness goals. We believe to achieve these goals there must be a partnership between you the patient and your health care team (our chiropractic clinic) as well as your other specialists. Together we will work together to treat your condition, manage long term diseases, limited exacerbations of recurrent problems and set achievable health goals. As your provider we will respect your privacy, engage in open and honest discussion pertaining to all your health concerns, seek opinions from other specialists and ensure after-hour access and same-day appointments, whenever possible. We wil end every visit making sure you hav eno questions, and leave with a clear direction of your care plan.

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

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