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.

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?

Insurance & Payment for Care

Primary Insurance
Secondary Insurance

If an auto accident, please provide:

Personal Health History

Family/Primary Physician

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Personal Incident History:

If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

Family Health History

Separate details with "," comma as shown above.

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

Social History & Life Choices:


Chiropractic Experience

Please select all that apply.


If yes…

What was the reason for those visits?

Doctor's Name:

Approximate date of last visit:

Reason for this Visit

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

Does this concern interfere with:


For Women Only


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...

Health Problems & Concerns:

Please select all that you have had or currently have.

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:


(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.

Name of the Insured:
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Patient's/Guardian's signature:


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