Chiropractic Spine Center
1930 Pearl Rd, Suite 2
Brunswick, OH 44212
330-220-2001
www.myclevelandchiropractor.com

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.)

   

Draw Your Symptoms


Click on a crayon and draw on the body above to indicate your symptoms
Ache / Dull Sharp / Stabbing Numb / Tingling Pins & Needles Burning Throbbing Cramping Radiating Other Pains eraser eraser clear

Employment Information


Current Symptoms


If Yes, Explain:

If yes:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Where?




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:

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:

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

T e r m s o f A c c e p t a n c eThe goal of our office is to enable patients to gain control of their health. To attain this we believe communication is the key. There are often topics that are hard to understand and we hope this document will clarify those issues for you. Please read below and if you have any questions please feel free to ask one of our staff members.Informed consent:I certify that I am the patient or legal guardian listed above.I give the Chiropractic doctor permission and authority to care in accordance with the chiropractic tests, diagnosis and analysis. The chiropractic adjustment or other clinical procedures are usually beneficial and seldom cause any problems. In rare cases underlying physical defects, deformities or pathologies may render the patient susceptible to injury. The doctor will not give any treatment or care if he is aware that such care may be contra-indicated. It is my responsibility to make it known, or to learn through healthcare procedures what I am suffering from: latent pathological defects, illnesses, or deformities which would otherwise not come to the attention of the Chiropractic physician. The Chiropractic doctor provides a specialized, non-duplicating health care service. Your doctor of chiropractic is licensed in a special practice and is available to work with other types of providers in your health care regimen. I understand if I am accepted as a patient by a physician at The Ohio State Chiropractic Association, I am authorizing them to proceed with any treatment they deem necessary. Any risk involved regarding chiropractic treatment will be explained to me upon my request.Cancelled/Missed Massage AppointmentsAny massage appointment not cancelled or rescheduled 24 hours prior to the scheduled appointment will be charged a $25 fee.Notice of Acupuncture Financial Policy for ALL PatientsChiropractic Spine Center DOES NOT bill insurance for acupuncture treatments. Patients have the option of submitting their paid acupuncture records/receipts to their insurance company, from which the insurance company may or may not reimburse the patient.Notice of Payment Policy for ALL PatientsAll payments, co-pays & co-insurances, are due at time of service unless arrangements are made for monthly auto-debit payments. A 3% processing fee will be applied to all requested refunds.Acknowledgement of HIPPAI have read and fully understand the above statements. I have reviewed the Notice of Privacy Practices (HIPPA) and have been provided an opportunity to discuss my right to privacy. Upon request I will be given a copy.

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

Signature


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