Complete Chiropractic & Wellness Center
637 Village View
Hickman, NE 68372
402-792-2135

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

Personal Information

Contact Information

*First Name:
Middle Name:
*Last Name:
*Gender:	Female Male
*Date of Birth:
Social Security #:
Height:	Feet Inches
Weight:
Marital Status:
Spouse's Name:
Number of Children:

Emergency Contact:
Relationship:
Phone:

*Email:
	(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.)
*Home Phone:
Cell Phone:
Work Phone:

Country:
Address Line 1:
Address Line 2:
City:
State/Province/Region:
*Zip/Postal Code:

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Draw Your Symptoms

Click on a crayon and draw on the body above to indicate your symptoms

How did you find out about our office?

Referring Physician:
Referring Patient:
Referred by:

Did you hear about our office from an advertisement?

No Yes

If Yes, Where:

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

No Yes

If Yes, Where:

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Employment Information

Regular Work Status:
Employer Name:
Employer Address:
Employer City:
Employer State:
Employer Zip:
Occupation:
Supervisor Name:
Supervisor Phone/Extension:
Physical Work Duties:

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What is the purpose of your visit?

Wellness Complaint Injury Other

Current Symptoms

Where did the injury occur?

Automobile Work 3rd Party Premises Other

Date of Injury:

Please Describe how the injury, pain, or discomfort originated:

Please describe your pain/discomfort:

Select frequency you experience pain from this condition:

Always Hourly Daily Occasionally

Does this condition interfere with any of your daily activities or routines?

No Yes

Has this condition affected your quality of sleep or ability to sleep?

No Yes

Has this condition affected your appetite?

No Yes

If Yes, Explain:

Have you missed any work due to this injury?

No Yes

If yes:
Select unable to work from date:
Select day you have or will return to work:

Have you reduced or limited your work hours because of this condition?

No Yes

If Yes, Explain:

Is the pain/discomfort worse at certain times of the day?

No Yes

If Yes, Explain:

Does the weather affect your pain/discomfort?

No Yes

If Yes, Explain:

List anything that aggravates your condition:

List anything that relieves or improves your condition:

Have you received professional treatment for this condition?

No Yes

If Yes, Explain:

Have you had X-rays taken for this condition?

No Yes

If Yes, Where?

Pain level Rating - Scale 1 to 10 (Where 1 is least pain and 10 is maximum pain)

At its best: At its Worst: Current Level:

Have you ever had this same condition?

No Yes

If Yes, When?:

List other practitioners seen for this injury/condition:

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Personal Health History

Family/Primary Physician

Date of Last Physical Exam:
Name of Family Physician or Physician Seen:
Physician Phone:
Physician City:
Physician State:
Physician Zip:

Please list any health conditions that you have been treated for in the last year:
(condition, cause, current/resolved)

Separate details with "," comma as shown above.

Have you had previous chiropractic care?

No Yes

Condition(s) treated:

Date of last chiropractic visit:

Are you pregnant, or have you had any signs of pregnancy? (Female Only)

No Yes

Are you planning to get pregnant in the next 12 months? (Female Only)

No Yes

List current medications:
(name, amounts, frequency, length of use, reason for use)

Separate details with "," comma as shown above.

List current vitamins, minerals, supplements, or herbs:
(name, amounts, frequency, length of use, reason for use)

Separate details with "," comma as shown above.

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Personal Incident History:

Broken Bones?

No Yes

If yes:
Did you get professional care/treatment?
No Yes

Briefly Explain:

Had Major Sprains/Strains?

No Yes

If yes:
Did you get professional care/treatment?
No Yes

Briefly Explain:

Been Hospitalized?

No Yes

Briefly Explain:

Had Surgery?

No Yes

Briefly Explain:

Been In Auto Accident?

No Yes

If yes:
Did you get professional care/treatment?
No Yes

Briefly Explain:

Been Struck Unconscious?

No Yes

If yes:
Did you get professional care/treatment?
No Yes

Briefly Explain:

Been Diagnosed with an Eating Disorder?

No Yes

Briefly Explain:

Had a Stroke?

No Yes

Briefly Explain:

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Family Health History

Please list diagnosed health conditions and untimely deaths.(condition, relationship to you)
(Family members include: Parents and siblings and maternal and paternal grandparents/aunts/uncles)

Separate details with "," comma as shown above.

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

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Chiropractic Experience

Who referred you to our office?

Where did you hear about us?…

Please select all that apply.

Newspaper Sign Yellow Pages Community Event Mailing Other

Other:

Have you been adjusted by a chiropractor before?

Yes No

If yes…

What was the reason for those visits?

Doctor's Name:

Approximate date of last visit:

Has any member of your family ever seen a wellness chiropractor?

Yes No

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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.

I want the Doctor to select the type of care appropriate for my condition.

Relief care: Symptomatic relief of pain or discomfort.
Corrective care: Correcting and relieving the cause of the problem as well as the symptom.
Comprehensive care: Bring whatever is malfunctioning in the body to the highest state of health possible with Chiropractic care.

Health Problems & Concerns:

Please select all that you have had or currently have.

Other:

Have you had any of these Cardiovascular Diseases? Please select all that apply.

Myocardial infarction Hypertension Hypercholesterolemia Bypass surgery
Coronary artery disease

Do you have Diabetes? If so what type?

Type I Type II Juvenile

Do you have any stomach/digestive issues? Please select all that apply.

Ulcers Reflux IBS

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Worker's Compensation

Who saw the accident? Title:
Who reported the accident? Title:
Type of windows: Type of shop:
Do you use hand or foot levers?YesNo Do you work overhead?YesNo
Are you tired when you go home?YesNo

Describe the accident?

Do you lift from?

Ground Bench Platform Box Pallet Other

Do you have to reach?

YesNo Explain:

Is your work area cluttered?

YesNo Explain:

Do you push or pull?

YesNo Explain:

Do you pick up or lift?

YesNo How Much: How Often:

Do you lift in and out of a machine?

YesNo If so, do you:

Type of Floor:

If other describe:

Type of ventilation:

If other describe:

Type of lighting:

If other describe:

Is your work area:

If other describe:

Do you have any other jobs?

YesNo If yes, what type:

Has outside help been hired?

YesNo If yes, why:

Do you use a cart?

YesNo Type of Wheels:
Condition of cart: GoodBad Other If other, explain:
# of carts being moved at once: Weight moved per day:
From where to where:

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Auto Accident

Date & Time: Make & Model:
Street / Location: # of persons in your vehicle
Were you the: Were you:
Speed of your vehicle: Speed of their vehicle:
Were you wearing a seat belt?YesNo Have you worked since this injury?YesNo
Are your work activities restricted?YesNo Were there any witnesses?YesNo
Did the vehicle have airbags?YesNo Did the airbags inflate?YesNo
Did the police arrive?YesNo Police report filed?YesNo

Visited a Hospital or Doctor?

YesNo Name of hospital:
When did you go to the hospital?
How did you get to the hospital?
Was the Doctor a?
Were any X-rays taken?YesNo
Medication prescribed?YesNo

Were you rendered unconscious?

YesNo How long?

Traffic violation issued?

YesNo To Whom?

Retained an attorney?

YesNo Name: Phone:

In relation to the base of your skull, where was the headrest?

Impact to your vehicle came from?

The direction you were heading?

The direction they were heading?

The direction you were facing?

What did your vehicle impact?

Explain:

Strike anything in the vehicle?

Explain:

Describe the accident?

How did you feel right after?

Names of all persons in this accident:

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Authorization

Patient Health Information Consent FormWe want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we will begin any health care treatments we must require you to read and sign this consent form stating that you understand and agree with how your records will be used. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent.1. The patient understands and agrees to allow this chiropractic office to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations, and coordination of care. As an example, the patient agrees to allow this chiropractic office to submit requested PHI to the Health Insurance Company (or companies) provided to us by the patient for the purpose of payment. Be assured that this office will limit the release of all PHI to the minimum needed for what the insurance companies require for payment.2. The patient has the right to examine and obtain a copy of his or her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI. Our office is not obligated to agree to those restrictions.3. A patient's written consent need only be obtained one time for all subsequent care given the patient in this office.4. The patient may provide a written request to revoke consent at any time during care. This would not effect the use of those records for the care given prior to the written request to revoke consent but would apply to any care given after the request has been presented.5. For your security and right to privacy, all staff has been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures in our office. We have taken all precautions that are known by this office to assure that your records are not readily available to those who do not need them.6. Patients have the right to file a formal complaint with our privacy official about any possible violations of these policies and procedures.7. If the patient refuses to sign this consent for the purpose of treatment, payment and health care operations, the chiropractic physician has the right to refuse to give care. I have read and understand how my Patient Health Information will be used and I agree to these policies and procedures.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 and that failure to pay in timely manner may result in late fees. 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.

* I agree with this statement of authorization

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

Signature

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