City Chiro Sports Center
2240 Marketplace

Suite 160
Irving, TX 75063
972-556-2500

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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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.

What is the purpose of your visit?

What is the reason for this visit?

Date of scheduled appointment

When did this condition begin?

How long have you had this condition?

What caused this condition?

Where is the discomfort?

Select only one area of discomfort for your chief complaint. Add additional areas of discomfort as additional complaints by selecting Yes in response to Do you have an additional complaint? at the bottom of this section.

Head

Front of head

Right side of head

Back of head

Left side of head

Neck

Front of neck

Right side of neck

Back of neck

Left side of neck

Back

Right mid back

Central mid back

Left mid back

Right low back

Central low back

Left low back

Trunk

Abdomen

Back of ribs

Chest

Right side of ribs

Front of ribs

Left side of ribs

Upper Extremity

Front of right upper extremity

Front of left upper extremity

Rear of right upper extremity

Rear of left upper extremity

Front of right shoulder

Front of left shoulder

Rear of right shoulder

Rear of left shoulder

Front of right upper arm

Front of left upper arm

Rear of right upper arm

Rear of left upper arm

Front of right elbow

Front of left elbow

Rear of right elbow

Rear of left elbow

Front of right wrist

Front of left wrist

Rear of right wrist

Rear of left wrist

Front of right hand

Front of left hand

Rear of right hand

Rear of left hand

Lower Extremity

Front of right lower leg

Front of left lower leg

Rear of right lower leg

Rear of left lower leg

Front of right hip

Front of left hip

Rear of right hip

Rear of left hip

Front of right thigh

Front of right knee

Rear of right thigh

Rear of right knee

Front of left thigh

Front of left knee

Rear of left thigh

Rear of left knee

Front of right leg

Front of right ankle

Rear of right leg

Rear of right ankle

Front of left leg

Front of left ankle

Rear of left leg

Rear of left ankle

Top of right foot

Top of left foot

Bottom of right foot

Bottom of left foot

Right side of right foot

Right side of left foot

Left side of right foot

Left side of left foot

OTHER

Does the discomfort radiate/travel?

Yes No

Describe the quality of the discomfort. Choose all that apply.

Aching

Sharp

Annoying

Shock-like

Burning

Shooting

Deep

Stabbing

Diffuse

Stiffness

Dull

Throbbing

Heavy

Tightness

Intolerable

Tingling

Pulling

OTHER

Describe the onset of the discomfort. Choose only one.

Gradual Insidious Recent Spontaneous Sudden Traumatic Unknown

Describe the intensity of the discomfort. Choose only one.

Mild Mild to moderate Moderate Moderate to severe Severe

Rate the severity of your discomfort on a scale of 1-10 where 1 is the least severe and 10 is the most severe.

1 2 3 4 5 6 7 8 9 10

Least severe <----------------------------> Most severe

How often do you feel this discomfort? Choose only one.

Constant Frequent Intermittent On and off Random Recurring

How has this complaint changed since the onset?

Improved Stayed the same Worsened

What activity is most significantly affected by this discomfort?

What aggravates this condition? Choose all that apply.

Almost any movement

Love life

Athletic activity and/or exercise

Lying down

Bathing

Pulling

Bending

Pushing

Caring for family

Reaching

Carrying

Reading

Changing positions

Repetitive motions

Climbing stairs

Resting

Computer use

Running

Concentrating

Self care (dressing, bathing, etc.)

Cooking

Shaving

Coughing and/or sneezing

Sitting

Daily child or pet care

Squatting

Driving

Standing

Eating

Stress

Falling or staying asleep

Stretching

Getting in or out of car

Talking on telephone

Getting out of bed

Turning

Getting up from lying down

Twisting

Getting up from sitting

Unknown

Grocery shopping

Walking

Household chores

Working

Lifting

Yard work

Looking over shoulder

OTHER

What improves this condition? Choose all that apply.

Nothing

What treatment have you received for this condition up to now?

None

Were any diagnostic tests performed to assess this condition (including X-rays, MRIs, etc.)?

Yes No Unsure

Have you ever had any previous episodes of this condition?

Yes No

In what ways does this condition affect your life and your ability to function? Choose all that apply.

Bending over

Looking over shoulder

Caring for family

Love life

Climbing stairs

Lying down

Concentrating

Reaching overhead

Dressing myself

Rising out of chair or bed

Driving a car

Showering or bathing

Exercising

Sitting

Getting in/out of car

Standing

Getting to sleep

Staying asleep

Grocery shopping

Using a computer

Household chores

Walking

Lifting objects

Yard work

Do you have an additional complaint?

Yes No

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Mechanism of Injury

The injury was due to: (choose one)

What date did the accident happen?

Where were you (or was the patient) looking at the time of impact?

Did you (or the patient) receive an injury to the head?

Yes No

Did your (or the patient) lose consciousness?

Yes No

Did police arrive at the scene?

Yes No

Was an accident report taken?

Yes No

Did Emergency Medical Services arrive at the scene?

Yes No

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?

Admitted

Referred to a chiropractor

Examination was performed

Referred to a neurologists

Home treatment with cold

Referred to orthopedists

Home treatment with heat

Referred to primary care provider

Home treatment w/ over-the-counter medication

Released

Home treatment with rest

Released that day

Medication was prescribed

Surgery

No treatment since accident

X-rays were completed

Physical therapy

OTHER

Referred for further evaluation and treatment

What was the location of symptoms felt at the time of the accident? Choose all that apply.

Head

Front of head

Right side of head

Back of head

Left side of head

Neck

Front of neck

Right side of neck

Back of neck

Left side of neck

Back

Right mid back

Central mid back

Left mid back

Right low back

Central low back

Left low back

Trunk

Abdomen

Back of ribs

Chest

Right side of ribs

Front of ribs

Left side of ribs

Upper Extremity

Front of right forearm

Front of left forearm

Rear of right forearm

Rear of left forearm

Front of right shoulder

Front of left shoulder

Rear of right shoulder

Rear of left shoulder

Front of right upper arm

Front of left upper arm

Rear of right upper arm

Rear of left upper arm

Front of right elbow

Front of left elbow

Rear of right elbow

Rear of left elbow

Front of right wrist

Front of left wrist

Rear of right wrist

Rear of left wrist

Front of right hand

Front of left hand

Rear of right hand

Rear of left hand

Lower Extremity

Front of right lower leg

Front of left lower leg

Rear of right lower leg

Rear of left lower leg

Front of right hip

Front of left hip

Rear of right hip

Rear of left hip

Front of right thigh

Front of right knee

Rear of right thigh

Rear of right knee

Front of left thigh

Front of left knee

Rear of left thigh

Rear of left knee

Front of right leg

Front of right ankle

Rear of right leg

Rear of right ankle

Front of left leg

Front of left ankle

Rear of left leg

Rear of left ankle

Top of right foot

Top of left foot

Bottom of right foot

Bottom of left foot

Right side of right foot

Right side of left foot

Left side of right foot

Left side of left foot

OTHER

Describe the discomfort felt at the time of the accident. Choose all that apply.

Aching

Sharp

Burning

Shock like

Deep

Shooting

Diffuse

Stiffness

Dull

Throbbing

Heavy

Tightness

Numbness

Tingling

Pulling

OTHER

Are there any additional symptoms which appeared since the accident happened? Choose all that apply.

None

Describe the status of your symptoms since the accident. Choose all that apply.

Deteriorated daily functioning at home/work

Improved daily functioning at home/work

Disappeared

Lessened

Elicited less stiffness

Shown no change in daily functioning at home/work

Elicited more stiffness

Somewhat resolved

Elicited less pain

Stayed the same

Elicited more pain

Worsened

Exacerbated

Worsened quality of life

Improved

OTHER

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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

Insurance & Payment for Care

How do you plan to pay for care?

Personal Insurance Third-Party Insurance No Insurance, Self-Pay

Name of Party Responsible for Payment:
Responsible Party Phone:

Primary Insurance

Secondary Insurance

Insurance Name:
Phone:
Address:
City:
State:
Zip:
ID/Policy #:
Group #:
Insured's Name:
Insured's Date of Birth:

Insurance Name:
Phone:
Address:
City:
State:
Zip:
ID/Policy #:
Group #:
Insured's Name:
Insured's Date of Birth:

If an auto accident, please provide:

Claim #:
Insurance Contact Person:
Insurance Phone:
Attorney's Full Name:
Attorney's Phone:

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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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Social History & Life Choices:

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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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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.

* I agree with this statement of authorization

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

Finalizing Form

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Service provided by:

Alcohol Daily Weekly Occasionally Never	Caffeine Drinks & Products Daily Weekly Occasionally Never
Diet Food Products Daily Weekly Occasionally Never	Drugs Daily Weekly Occasionally Never
Energy Products or Over-the-Counter Stimulants Daily Weekly Occasionally Never	Exercise Daily Weekly Occasionally Never
Fresh & Homemade Foods Daily Weekly Occasionally Never	Preprocessed, Packaged, & Restaurant Food Daily Weekly Occasionally Never
Soft Drinks Daily Weekly Occasionally Never	Tobacco Daily Weekly Occasionally Never
Water Daily Weekly Occasionally Never

Patient Intake Form

Patient Information

Complaint Information

Complaint #2 Information

Complaint #3 Information

Complaint #4 Information

Mechanism of Injury

Draw Your Symptoms

How did you find out about our office?

Employment Information

Insurance & Payment for Care

Personal Health History

Social History & Life Choices:

Health Problems & Concerns:

Authorization

Signature

Finalizing Form