Gunderman Chiropractic and Wellness
PO Box 982
5701 George Washington Memorial Way
Yorktown, VA 23692
757-874-5666

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.)

   

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

Neck

Back


Trunk

Upper Extremity






Lower Extremity





Does the discomfort radiate/travel?
Describe the quality of the discomfort. Choose all that apply.
Describe the onset of the discomfort. Choose only one.
Describe the intensity of the discomfort. Choose only one.
Rate the severity of your discomfort on a scale of 1-10 where 1 is the least severe and 10 is the most severe.
Least severe <----------------------------> Most severe
How often do you feel this discomfort? Choose only one.
How has this complaint changed since the onset?
What activity is most significantly affected by this discomfort?
What aggravates this condition? Choose all that apply.
What improves this condition? Choose all that apply.
What treatment have you received for this condition up to now?
Were any diagnostic tests performed to assess this condition (including X-rays, MRIs, etc.)?
Have you ever had any previous episodes of this condition?
In what ways does this condition affect your life and your ability to function? Choose all that apply.
Do you have an additional complaint?

Past, Family and Social History


List your (or the patient's) past surgical history. Choose all that apply and indicate the year in which the surgeries were performed.
Describe any past illnesses or conditions the doctor should be aware of and the age at which the illness(es) reportedly occurred. Respond respectively to each illness listed. If personal health history is good, select "No past illnesses (including diabetes, cancer, hypertension and progressive neurological diseases)"





List any past history of accidents or trauma. Choose all that apply.
Are you presently taking any medication?
List your (or the patient's) family health history. Choose all that apply to blood relatives only.
What are your (or are the patient's) current work habits? Choose all that apply.



How would you describe your (or the patient's) personal social habits? Choose all that apply.




How would you describe your (or the patient's) present exercise habits? Choose all that apply.
How would you describe your (or the patient's) diet and nutritional status? Choose all that apply.

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

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


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.

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:

For Women Only

COMPLETE THIS SECTION ONLY IF YOU ARE (OR THE PATIENT IS) A WOMAN OVER 16 YEARS OF AGE.

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.




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

Thank you for choosing Gunderman Chiropractic and Wellness Center as your chiropractic healthcare provider. We are committed to your treatment being successful and rewarding. I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Gunderman Chiropractic all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges (including co-pays and deductibles) whether or not paid by the insurance. I hereby authorize the release of any medical information from this office that is necessary to process claims with my insurance company. I authorize the use of this signature on all insurance submissions. 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. This office requires that fees be paid at the time of service. As a courtesy to our patients, we will file claims with your insurance carrier, although you are responsible for the entire balance the day service is rendered. If any other arrangements need to be made, they must be discussed with the insurance manager BEFORE any treatment is given. All charges not collected within 90 days of original service, either from the patient or the insurance carrier, shall be forwarded to a collection agency. *Medicare (if applicable) Medicare covers Chiropractic office visits after the annual deductible has been met. Medicare does not cover any services other than the spinal adjustment (i.e. Laser, footbaths, ultrasound, percussor, etc.). Because Medicare does not cover these additional services, they will not be applied to your annual deductible. Services will be considered for payment based on medical necessity. In order to prove that these services are medically necessary, the treating doctor will perform an exam/xray annually to document that these services are not maintenance. This ensures that Medicare will cover 80% of the visit after the deductible has been satisfied. Medicare will only pay 80% of the manipulation charge, therefore if you do not have a Medicare supplement or secondary insurance, you will be responsible for the remaining 20%. By signature, I signify that this office has explained Medicare to me and I agree to personally pay for all charges not covered by Medicare, which is required by law at the time of service. *Cancellation Policy Due to growth in our business, appointment availabilities at Gunderman Chiropractic have become increasingly limited. Because of this and our patients’ need for treatment, there is a $45.00 charge for missed appointments that are not cancelled at least 3 hours prior to your appointment time. Additionally, if you are more than 15 minutes late for your appointment, we may need to reschedule your appointment in order to maintain appointment schedules. Leniency in this policy has been granted in the past; however, growth in business requires that we now enforce this. As a courtesy to our patients, we remind you of your appointment at least one day in advance. It is your responsibility to cancel your appointment if for any reason it cannot be kept. By signing this form, you agree and understand that for any missed appointment without proper notice YOU will be charged a $45.00 missed appointment fee, and it will be paid with the understanding that you did not notify the office in a timely manner to cancel your appointment(s). If you miss 3 or more appointments without proper notice, or are 30 minutes or more late, we will be unable to schedule an appointment for you and therefore you will be placed on a waiting list and called when there is an opening. Thank you for your cooperation in this matter, and we appreciate your consideration of others. 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 authorize this office and its staff to examine and treat my condition as the doctors see fit.

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

Signature


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