Chiro Sport Health Center
22020 Clarendon St
Suite 101
Woodland Hills, CA 91367
818-346-9233

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.)

   

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:

Reason for this Visit

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

Does this concern interfere with:





Results:

Electronic Health Record (EHR) Information


Preferred Language: Ethnicity:
Race:
Smoking Status: Smoking Start Date:
Type of Tobacco:
Have you tried to quit? How much tobacco do you use?
How long have you used tobacco?
Current Medications And Dosage:
Medication Name Dosage
Medication Allergies:
Medication Name Reaction Date Discovered

Authorization

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. Chiropractic Informed Consent to TreatTo the patient: Please read this entire document prior to signing it. It is important that you understand the information contained in this document. If there is anything that is unclear, please ask questions before you sign. The nature of the chiropractic adjustment: The primary treatment I use as a Doctor of Chiropractic is spinal manipulative therapy. I will use that procedure to treat you. I may use my hands or a mechanical instrument upon your body in such a way to move your Vertebra (spinal bones) to improve the joint function. That may cause an audible “pop” or “click,” much as you’ve experienced when you “crack” your knuckles. You may feel a sense of movement. Analysis / Examination: As a part of the analysis, examination, and treatment you are consenting to the following procedures:Talk about current condition • Postural analysis •Talk about your past medical history •Orthopedic and neurological testing•Inspect, touch or exam area of concern•Orthotic diagnostic studies ( X-ray, MRI, Nerve test and ultrasound)• Vital Signs•Range of motion testing• Muscle strength testing Treatment:•Spinal manipulative therapy •Ultrasound • Massage table • Electronic muscle stimulation•Therapeutic massage, stretching, and exercising • Hot / cold therapy •Cold laser •Nutritional counseling •Assistance and treatment by support staffThe material risk inherent in chiropractic adjustment: As with any health care procedure, there are certain complications which may arise during chiropractic manipulation and therapy. These complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, costovertebral strains, separations, and burns. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to serous complications including stroke. Some patients will feel some stiffness and soreness following the first few days of treatment. I will make every reasonable effort during the examination to screen for contraindication to care; however, if you have a condition that would otherwise not come to my attention, it is your responsibility to inform me. The probability of those risks occurring:Fractures are rare occurrences and generally result from some underlying weakness of the bone, which I check for during you history, examination and X-ray testing. Stroke has been the subject of tremendous disagreement. The incidences of stroke are exceedingly rare and are estimated to occur between one in one million and one in five million cervical adjustments. The other complications are also generally described as rare. The availability and nature of other treatment options:Other treatment options for your condition may include: •Self administered, over the counter analgesics and rest•Medical care and prescription drugs such as anti-inflammatories, muscle relaxants’ and pain relievers •Hospitalization •Surgery •Physical therapy •Second opinionIf your chose to use one of the above noted “other treatment” options, you should be aware that there are risk and benefits of such options and you may wish to discuss these with your physicianDO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE. PLEASE PUT A CHECK IN THE APPROPRATE BOX AND SIGN BELOW

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

Signature


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