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.
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.
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.
Authorization
When a person seeks chiropractic health care and we accept a person for such care, it is essential for both parties to be working towards the same objective. Chiropractic has only one goal. It is important that each person understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment. Adjustment: An adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine.Health: A state of optimal physical, mental, and social well being, not merely the absence of disease or infirmity.Vertebral Subluxation: A misalignment of one of the 24 vertebra in the spinal column that causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body’s innate ability to express its maximum health potential.We do not offer to diagnose or treat a disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis, or treatment for those findings, we will recommend that you seek the services of another health care provider. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body’s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations. HIPPA Privacy Practices: I authorize my health care provider to use a telephone system and/or email to use my name, address, phone number, the name of my scheduled treating chiropractor, and the time and place of my scheduled appointment(s), for the limited purpose of contacting me to notify me of a pending appointment or other health related communications. I also authorize my health care provider to disclose to third parties who answer my phone limited protected health care information regarding pending appointments and to leave a reminder message on my voice mail system and/or answering machine. 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.
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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