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
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Personal Information
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Contact Information
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(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.)
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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.
Mechanism of Injury
The injury was due to: (choose one)
What date did the accident happen?
FOR WORKMAN'S COMPENSATION-RELATED VISITS ONLY: How did the injury occur? Choose all that apply.
As a pedestrian, what were you (or was the patient) doing at the time of the accident?
Where were you (or was the patient) looking at the time of impact?
Did you (or the patient) receive an injury to the head?
Did your (or the patient) lose consciousness?
What part of your (or the patient’s) vehicle was impacted? Choose all that apply.
In what direction was your (or the patient's) vehicle moving?
What was the estimated speed of your (or the patient’s) vehicle?
What was the extent of the damage to your (or the patient's) vehicle?
What was the extent of the damage to the other vehicle?
In what direction was the other vehicle moving?
What was the estimated speed of the other vehicle?
Was your (or the patient’s) vehicle towed from the scene?
Did police arrive at the scene?
Was an accident report taken?
Did Emergency Medical Services arrive at the scene?
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?
What was the location of symptoms felt at the time of the accident? Choose all that apply.
Head
Neck
Back
Trunk
Upper Extremity
Lower Extremity
Describe the discomfort felt at the time of the accident. Choose all that apply.
Are there any additional symptoms which appeared since the accident happened? Choose all that apply.
Describe the status of your symptoms since the accident. Choose all that apply.
Review of Systems
Musculoskeletal
Neurological
Head, Eyes, Ears, Nose and Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Endocrine
Dermatological and Bleeding
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?
Which of the following medications are you presently taking? Choose all that apply.
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.
Intensive Pediatric Evaluation
COMPLETE THIS SECTION ONLY IF THE PURPOSE OF THE VISIT IS AN INTENSIVE PEDIATRIC EVALUATION.
Physical Stressors
Were there any significant falls or traumas to the mother during the pregnancy?
List any evidence of birth trauma:
Does the child have any history of serious falls or injuries, including fractures, concussions, hospitalizations, etc.?
Does the child wear a backpack?
Does child participate in sports or exercise activities?
Does child engage in any hobbies or activities which require prolonged, awkward or repetitive postures (violin, gymnastics, ballet, etc.)?
Chemical Stressors
As an infant, was the child breastfed?
Was formula introduced?
Was cow's milk introduced?
Have solid foods been introduced?
Does the child have any food, liquid or juice intolerances or allergies?
During the pregnancy, did the mother smoke?
During the pregnancy, did the mother drink alcohol?
During the pregnancy, did the mother use recreational drugs?
Did the mother suffer any illnesses during the pregnancy?
Were any nutritional supplements prescribed or taken during the pregnancy?
Were ultrasound(s) performed during the pregnancy?
Were any invasive procedures performed during the pregnancy (Amniocentesis, Cerclage, etc.)?
Are there any pets in the child's home?
Are there any smokers in the child's home or environment?
Has the child had any adverse reactions to vaccinations or medicines?
Is there any history of antibiotics given to the child?
Psychosocial Stressors
Have there been any difficulties with child-parent bonding?
Does the child have any behavioral problems?
Have any of the following behaviors occurred? Check all that apply.
On average, how many hours per week of television does the child watch?
Do you feel the child’s social and emotional development is normal for their age?
Was there any delay in terms of the child's achievement of developmental goals? Choose all that apply.
Draw Your Symptoms
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Click on a crayon and draw on the body above to indicate your symptoms
Employment Information
Insurance & Payment for Care
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Primary Insurance
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Secondary Insurance
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If an auto accident, please provide:
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.
Social History & Life Choices:
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.
Were You Aware That...
Authorization
I certify that I'm the patient or legal guardian listed above. 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 and necessary for my condition. 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 clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I waive the right to claim a Statue of Limitations regarding claims for services rendered and agree to pay reasonable costs of collection, including attorney fees and court costs if incurred. Fees are payable at the time services are rendered, unless other arrangements are made in advance. I agree to pay for services in full if my insurance company should deny coverage for preventative, supportive or maintenance care. I also understand that if I suspend or terminate my care or treatment, any fees for professional services rendered to me will be immediately due and payable. I hereby authorize this clinic to administer chiropractic care, perform diagnostic tests including x-rays and perform other treatments to the above named minor child. As of this date, I have the legal right to select and authorize health care services for the minor child named above. Should x-rays be taken, they remain property of this clinic and the doctor’s records. In the event that I am referred to another physician or my insurance company requests information, then I authorize the release of information acquired in the course of my examination and or treatment from Harmon Family Chiropractic to these sources. AUTHORIZATION FOR THE TAKING OF X-RAY FILMS AND RETENTION OF SAME: I hereby authorize the taking of analytical x-ray film(s) of any necessary areas of my body. I further agree that Harmon Family Chiropractic shall be the sole owner and controller of said analytical x-ray(s). **ATTENTION TO FEMALE PATIENTS**: If you are pregnant or suspect you may be pregnant, please advise the receptionist and the radiographer before your examination. I certify that I have read and understand the above information to the best of my knowledge. The questions will and have been accurately answered. I understand that I am responsible for completing these forms in full, and that providing incorrect or leaving out information can be dangerous to my health.
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Name of the Insured:
(Please Print)
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_____________________________________________
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Patient's/Guardian's signature:
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_____________________________________________
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Date:
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__________
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Signature