Custom Footworks PLLC
6842 Lebanon Suite 104
Frisco, TX 75034
972-913-6684

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:

(Back to Top) | (Go to Submit)

Employment Information

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

(Back to Top) | (Go to Submit)

What is the purpose of your visit?

Wellness Complaint Injury Other

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:

(Back to Top) | (Go to Submit)

Reason for this Visit

Describe the reason for this visit

Please briefly describe, including the impact it has had on your life.

If you're only here for chiropractic wellness services please skip this section.

Wellness Sports Auto Fall Home Injury Job Chronic Discomfort Other

Briefly Explain:

When did this concern begin?

Has this concern:

Gotten Worse Stayed Constant Come and Gone

Does this concern interfere with:

Work Sleep Daily Routine Other Activities

Briefly Explain:

Has this concern occured before?

Yes No

Briefly Explain:

Have you seen other doctors for this concern?

Yes No

Doctor's Name:

Type of Treatment:

Results: Good Bad Indifferent

(Back to Top) | (Go to Submit)

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

(Back to Top) | (Go to Submit)

Authorization

I understand and agree that all services rendered to me will be charged to me, and I'm responsible for immediately payment of such services.

* I agree with this statement of authorization

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

Signature

Finalizing Form

Print Form (optional)
Submit Form!

Service provided by:

Patient Intake Form

Patient Information

Draw Your Symptoms

Employment Information

Personal Incident History:

Reason for this Visit

Health Problems & Concerns:

Authorization

Signature

Finalizing Form