Jex Family Chiropractic

20536 108th Ave SE
Kent, WA 98031
Ph: 253-859-6441
Fx: 253-859-9437

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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Draw Your Symptoms

Click on a crayon and draw on the body above to indicate your symptoms

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

Current Symptoms

Where did the injury occur?

Automobile Work 3rd Party Premises Other

Date of Injury:

Please Describe how the injury, pain, or discomfort originated:

Please describe your pain/discomfort:

Select frequency you experience pain from this condition:

Always Hourly Daily Occasionally

Does this condition interfere with any of your daily activities or routines?

No Yes

Has this condition affected your quality of sleep or ability to sleep?

No Yes

Has this condition affected your appetite?

No Yes

If Yes, Explain:

Have you missed any work due to this injury?

No Yes

If yes:
Select unable to work from date:
Select day you have or will return to work:

Have you reduced or limited your work hours because of this condition?

No Yes

If Yes, Explain:

Is the pain/discomfort worse at certain times of the day?

No Yes

If Yes, Explain:

Does the weather affect your pain/discomfort?

No Yes

If Yes, Explain:

List anything that aggravates your condition:

List anything that relieves or improves your condition:

Have you received professional treatment for this condition?

No Yes

If Yes, Explain:

Have you had X-rays taken for this condition?

No Yes

If Yes, Where?

Pain level Rating - Scale 1 to 10 (Where 1 is least pain and 10 is maximum pain)

At its best: At its Worst: Current Level:

Have you ever had this same condition?

No Yes

If Yes, When?:

List other practitioners seen for this injury/condition:

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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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Personal Incident History:

Broken Bones?

No Yes

If yes:
Did you get professional care/treatment?
No Yes

Briefly Explain:

Had Major Sprains/Strains?

No Yes

If yes:
Did you get professional care/treatment?
No Yes

Briefly Explain:

Been Hospitalized?

No Yes

Briefly Explain:

Had Surgery?

No Yes

Briefly Explain:

Been In Auto Accident?

No Yes

If yes:
Did you get professional care/treatment?
No Yes

Briefly Explain:

Been Struck Unconscious?

No Yes

If yes:
Did you get professional care/treatment?
No Yes

Briefly Explain:

Been Diagnosed with an Eating Disorder?

No Yes

Briefly Explain:

Had a Stroke?

No Yes

Briefly Explain:

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Family Health History

Please list diagnosed health conditions and untimely deaths.(condition, relationship to you)
(Family members include: Parents and siblings and maternal and paternal grandparents/aunts/uncles)

Separate details with "," comma as shown above.

(Example: arthritis, cancer, diabetes, heart disease, kidney disease, high cholesterol, etc.)

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Social History & Life Choices:

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Chiropractic Experience

Who referred you to our office?

Where did you hear about us?…

Please select all that apply.

Newspaper Sign Yellow Pages Community Event Mailing Other

Other:

Have you been adjusted by a chiropractor before?

Yes No

If yes…

What was the reason for those visits?

Doctor's Name:

Approximate date of last visit:

Has any member of your family ever seen a wellness chiropractor?

Yes No

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Reason for this Visit

Describe the reason for this visit

Please briefly describe, including the impact it has had on your life.

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

Wellness Sports Auto Fall Home Injury Job Chronic Discomfort Other

Briefly Explain:

When did this concern begin?

Has this concern:

Gotten Worse Stayed Constant Come and Gone

Does this concern interfere with:

Work Sleep Daily Routine Other Activities

Briefly Explain:

Has this concern occured before?

Yes No

Briefly Explain:

Have you seen other doctors for this concern?

Yes No

Doctor's Name:

Type of Treatment:

Results: Good Bad Indifferent

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For Women Only

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

Are you pregnant?

No Yes

Are you nursing?

No Yes

Are you taking birth control?

No Yes

Do you experience painful periods?

No Yes

Do you have irregular cycles?

No Yes

Do you have breast implants?

No Yes

Do you perform a regular self breast examination?

No Yes

Do you take hormone replacement therapy (HRT)?

No Yes

Do you take oral contraceptives?

No Yes

Estimate the date of your most recent PAP/pelvic exam:

Date of last mammogram?

Date of Last Menstrual Period?

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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.

I want the Doctor to select the type of care appropriate for my condition.

Relief care: Symptomatic relief of pain or discomfort.
Corrective care: Correcting and relieving the cause of the problem as well as the symptom.
Comprehensive care: Bring whatever is malfunctioning in the body to the highest state of health possible with Chiropractic care.

Were You Aware That...

Doctors of Chiropractic work with the nervous system?

No Yes

The nervous system controls all bodily functions and systems?

No Yes

Chiropractic is the largest natural healing profession in the world?

No Yes

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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Worker's Compensation

Who saw the accident? Title:
Who reported the accident? Title:
Type of windows: Type of shop:
Do you use hand or foot levers?YesNo Do you work overhead?YesNo
Are you tired when you go home?YesNo

Describe the accident?

Do you lift from?

Ground Bench Platform Box Pallet Other

Do you have to reach?

YesNo Explain:

Is your work area cluttered?

YesNo Explain:

Do you push or pull?

YesNo Explain:

Do you pick up or lift?

YesNo How Much: How Often:

Do you lift in and out of a machine?

YesNo If so, do you:

Type of Floor:

If other describe:

Type of ventilation:

If other describe:

Type of lighting:

If other describe:

Is your work area:

If other describe:

Do you have any other jobs?

YesNo If yes, what type:

Has outside help been hired?

YesNo If yes, why:

Do you use a cart?

YesNo Type of Wheels:
Condition of cart: GoodBad Other If other, explain:
# of carts being moved at once: Weight moved per day:
From where to where:

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Auto Accident

Date & Time: Make & Model:
Street / Location: # of persons in your vehicle
Were you the: Were you:
Speed of your vehicle: Speed of their vehicle:
Were you wearing a seat belt?YesNo Have you worked since this injury?YesNo
Are your work activities restricted?YesNo Were there any witnesses?YesNo
Did the vehicle have airbags?YesNo Did the airbags inflate?YesNo
Did the police arrive?YesNo Police report filed?YesNo

Visited a Hospital or Doctor?

YesNo Name of hospital:
When did you go to the hospital?
How did you get to the hospital?
Was the Doctor a?
Were any X-rays taken?YesNo
Medication prescribed?YesNo

Were you rendered unconscious?

YesNo How long?

Traffic violation issued?

YesNo To Whom?

Retained an attorney?

YesNo Name: Phone:

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?

Explain:

Strike anything in the vehicle?

Explain:

Describe the accident?

How did you feel right after?

Names of all persons in this accident:

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Authorization

(1) AUTHORIZATIONS. PATIENT CONSENT TO X-RAY: I authorize the performance of diagnostic x-ray examination of myself which the doctor may consider necessary or advisable in the course of my examination and treatment. CONSENT TO X-RAY A MINOR: I certify I am the parent or legal representative/guardian of the child listed on this form. I authorize the performance of diagnostic x-ray examination of this child or ward which the doctor may consider necessary or advisable in the course of examination or treatment. X-RAY WARNING - FEMALES: REGARDING POSSIBILITY OF PREGNANCY: I certify to the best of my knowledge that I am not pregnant and that the doctor has my permission to perform diagnostic x-ray examination. I have been advised that certain x-ray examinations, particularly those involving the pelvis, can be hazardous to an unborn child. AUTHORIZATION AND ASSIGNMENT OF HEALTH BENEFITS: I certify that I'm the patient or legal guardian listed earlier in this form. 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 authorize direct payment of the "Health Benefits," "Medical Reimbursement" from a Third Party Payer, and/or "Government Benefits" otherwise payable to me, directly to: MARSH CHIROPRACTIC, P.S. I understand this office only accepts assignment when insurance pays directly. 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 fully understand when the insurance company verifies my benefits, it is not a guarantee or authorization to pay on claims submitted. I agree to pay my patient portion, plus any balance insurance does not reimburse for at the time of each visit. I agree to pay/settle any denied and unpaid claims. I further understand all claims submitted by this office are my responsibility and require my participation to settle regardless of my insurance company of assignment of benefits. AUTHORIZATION FOR CARE OF MINOR: I authorize the doctors and staff to perform any necessary services during diagnosis and care of my child. NOTICE OF PRIVACY PRACTICES PURSUANT TO HIPAA: I do hereby acknowledge that I have been allowed a copy of this office's Notice of Privacy Practices Pursuant to HIPAA and Consent for Use of Health Information and have reviewed it for myself or my minor dependent(s), and understand that a full copy of this office's HIPAA Compliance Manual is available upon request. I consent to the use of my health information in a manner consistent with the Notice of Privacy Practices Pursuant to HIPAA, the HIPAA Compliance Manual, State law and Federal Law. (2) CONFORMITY CLAUSES. CHIROPRACTIC: It is important to recognize the difference between Chiropractic and Medicine. Either can be important to your health but for entirely different reasons. Chiropractors seek to restore health through natural means and without the use of medicine or surgery. Although a medical diagnosis may be of great importance to a patient, such diagnosis does not necessarily assist the Chiropractor in his efforts. The Chiropractor's purpose is to restore health through the natural flow of energy in the nervous system. This gives the body maximum opportunity to heal itself. The success of the Chiropractic procedures often depends upon underlying causes and conditions. It is important to understand what to expect from Chiropractic and Medical services in order that you, the patient, can determine whether either or both may be of benefit to you. ANALYSIS: A Chiropractor conducts a Chiropractic analysis for the express purpose of determining whether there is evidence of spinal subluxations. When such subluxations are found, Chiropractic adjustments are given to restore proper spinal alignment. It is the Chiropractic premise that proper spinal alignment allows free nerve flow throughout the body and gives the body its best chance to restore health. Due to the complexities of nature, no Chiropractor can promise you specific results. This depends upon the recuperative powers of the body. DIAGNOSIS: Although Chiropractors are experts in Chiropractic analysis, they are not specialists in the field of diagnosis. Internists are medical specialists who are highly qualified to diagnose. Every chiropractic patient should be mindful of his/her own symptoms and should secure medical opinion if there is any concern as to the nature of his/her illness or injury. Your Doctor of Chiropractic may express an opinion as to whether or not you should take this step, but you should take the initiative if in doubt. CHIROPRACTIC ADJUSTMENTS: The patient, in coming to the Chiropractor, gives the Chiropractor permission and authority to adjust the patient in accordance with the chiropractic analysis. The Chiropractic adjustment is usually beneficial and seldom causes any problem. In rare cases, underlying physical defects, deformities, or pathology may render the patient susceptible to injury. The Chiropractor, of course, will not give a chiropractic adjustment if he/she is aware that any such condition exists. Again, it is the responsibility of the patient to make it known or to learn through medical procedures whether they are suffering from latent pathological defects, illness, or deformity which would otherwise not come to the attention of the Chiropractor. The patient should not look to the Doctor of Chiropractic for in-depth diagnostic procedures. The D.C. provides a specialized health service and does not and should not become involved in the patient's medical regimen. A patient should never ask or accept advice from a Chiropractor concerning the taking of prescriptive medicines. The Doctor of Chiropractic is not licensed in medical practices. WARNING: There have been rare cases of injury reported due to chiropractic adjustments. The following have a risk of occurrence less than 0.001%: stroke, paralysis, cerebral vascular disruption. RESULTS: The purpose of chiropractic services is to promote natural health through the release of maximum nervous energy. Since there are so many variables, it is difficult to predict the time schedule or efficacy of chiropractic procedures. Sometimes the response is phenomenal. In most cases there is a more gradual, but quite satisfactory, response. Occasionally, the results are mediocre or dismal. Two or more similar conditions may respond differently to the same chiropractic care. Many medical failures find quick relief through chiropractic. In turn, we must admit that conditions which do not respond chiropractically may come under control or be cured through medical science. The fact is the sciences of chiropractic and medicine may never be so exact as to provide definite answers to many problems. Both have made great strides in alleviating pain and controlling disease.

* I agree with this statement of authorization

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

Signature

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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