Paragon Chiropractic & Wellness
6405 Telegraph Bldg. H-3
H-3
Bloomfield Hills, MI 48322
248-590-2195

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?

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?
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.

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.

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

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 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 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 have been given an opportunity to review Paragon Chiropractic & Wellness Center’s notice of privacy practices written in plain language. The notice provides the uses and disclosure of my protected health information that may be made by this practice, my rights, and the practice’s legal duties with respect to my information. I understand that Paragon Chiropractic & Wellness Center reserves the right to change the terms of its Notice of Privacy Practices, and to make changes regarding all protected health information, at or controlled by this practice. If changes to the Policy occur, Paragon Chiropractic & Wellness Center will provide me an opportunity to review the review Notice of Privacy Practices upon request.Thank you for choosing us as your health care provider. This document is a summary of our financial policies, an explanation of your responsibilities and authorization to bill your insurance on your behalf for services rendered. You may be responsible for co-pays, deductibles and services provided which may not be considered a benefit under your policy. Your insurance may deny claims for a variety of reasons: 1. The services provided may not be a benefit of your insurance policy or may not be covered when provided by our office (such as Physiotherapy modalities, heat, massage, traction, exercise instruction, nutritional advice and or supplements.) 2. You may have exhausted benefits for the services provided. Medical Necessity or Medically Necessary generally means a determination based upon criteria and guidelines developed by your insurance carrier in consideration of generally accepted standard and practices. Their services must meet all of the following criteria: a. It is generally accepted as necessary and appropriate for the patient’s condition, given the symptoms, and is consistent with the diagnosis and; b. It is essential or relevant to the evaluation or treatment of the injury, condition or illness and is not mainly for the convenience of the member of the Physician and it is reasonably excepted to improve the patient’s condition or level of function or, in the case of diagnostic testing, the results are used in the diagnosis and /or management of the patient’s care. Patients/Responsible Party Agreement:- If my physician does not participate with my insurance company or my insurance company does not pay for the services provided, or I do not have insurance coverage, I agree to be personally and fully responsible for all payments.- I accept responsibility for all co-pays and or deductibles and agree to pay at the time of services.- I understand that a statement will be sent to my home address unless a request was made otherwise.- I understand there is a $25 return check fee for any personal check that is returned.- I understand that there is a $30 no show fee for Massage visits that are canceled without a 24 hour notice.- I understand that statements are sent out on a monthly basis. If payment is not made within the due date of the statement we reserve the right to add a $10 late fee each month that it goes unpaid. If I am experiencing financial difficulty and cannot pay the balance in full, it is my responsibility to contact the office and arrange a payment plan.- I understand that should my account be sent to a collection agency that a 30% collection fee will be assessed. Additionally any court or attorney fees that are incurred by this office will also be my responsibility. - I understand that the physicians time and my care is valuable. If I must cancel an appointment, I will call the office and reschedule the appointment in a timely manner.- I have signed this form prior to any services rendered and understand that if I do not meet my financial obligations with Paragon Chiropractic & Wellness Center, this may adversely affect the patient/physician relationship and the physicians may withdraw as care providers. INFORMED CONSENT FOR TREATMENT Please read the following statements carefully. Your signature at the bottom of this form indicates agreement with each of the statements listed above and gives us the permission to provide services as indicated below.I understand that if I wish to authorize Paragon Chiropractic and Wellness Center to disclose protected health information to any third party, I must request and sign an additional form with said individual's information. If I sign this authorization form I state hereby that I have read all disclosers about my rights to release health information under regulation in title 42 Code of Federal regulations, Part 2, and information defined by MCLA 333.5131. I understand that my protected health information disclosed under this authorization may be subject to disclosure by the individual named above and its privacy will no longer be protected by law.

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

Signature


Finalizing Form


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