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
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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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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?
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:
Employment Information
Current Symptoms
If Yes, Explain:
If yes:
If Yes, Explain:
If Yes, Explain:
If Yes, Explain:
If Yes, Explain:
If Yes, Where?
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.
Personal Incident History:
Family Health History
Separate details with "," comma as shown above.
(Example: arthritis, cancer, diabetes, heart disease, kidney disease, high cholesterol,
etc.)
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:
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.
Health Problems & Concerns:
Please select all that you have had or currently have.
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?
Auto Accident
Visited a Hospital or Doctor?
Were you rendered unconscious?
Traffic violation issued?
Retained an attorney?
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?
Strike anything in the vehicle?
Describe the accident?
How did you feel right after?
Names of all persons in this accident:
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.
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