Nittany Valley Chiropractic, LLC
611 University Drive
State College, PA 16801
814-234-5271

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.

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


Insurance & Payment for Care


Primary Insurance
Secondary Insurance

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.

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.




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?



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. State Law requires our office to obtain your informed consent prior to examination and treatment. The purpose of this information provided is to inform you, not alarm you. What you are being asked to sign is a simple confirmation that you have been informed of the following: EXAMINATIONS: X-rays: This office does not routinely x-ray, but if x-rays are needed based on exam finding and/or unresponsive care we will refer you for further diagnostic testing within one week. Chiropractic adjustment/manipulation: The doctor will use his hands or a mechanical device upon your body in such a way as to increase joint mobility. This procedure may cause an audible "pop" or "click" to be heard coming from your joints, which is not cause for alarm. There are some material risks involved in doing these procedures and they are as follows: Pain: Chiropractic treatments may result in a temporary increase in soreness in the area receiving treatment. Rib Fractures: Fractures caused by chiropractic treatments are rare. They occurs most frequently in patients with osteoporosis or weakened bones. If evidence of osteoporosis is suspected, the most appropriate, gentle treatments are used, minimizing the possibility of fractures to the ribs. Disc Injury: Chiropractic treatment is appropriate for the treatment of most back problems, including some disc problems. Occasionally, chiropractic treatment may aggravate or cause a problem if the disc is in a severely weakened state. However, this occurs so rarely that statistics to quantify the probability are unavailable, but the risk is very low. Stroke: The overall incidence of stroke in the general populations is about 2 er 1000 people. Although chiropractic adjustment/manipulation has been implicated as a possible cause of stroke, this possibility is extremely rare. Current research shows that the problem has been associated with a lack of diagnosis and not the manipulations (Cassidy). Chiropractic is a system of health care delivery. As with an health care delivery system we cannot promise a cure for any symptom, disease, or condition as a result of treatment in this office. We will always five you our best care, and if your results are not acceptable, we will refer you to another health care provider who we feel will assist your situation. Assignment and Release: I understand that chiropractic is manual health care and requires direct contact between the doctor/ staff and patient. I authorize the taking of photographs and x-rays to be used for treatment purposes. I authorized the use of my phone number and email for phone calls, emails, and text reminders. I authorize the performance of other diagnostics and therapeutic procedures for treatment purposes. I understand that the doctor may want my x-ray films read by a Radiologist and i will be charged a fee for that reading. I authorize my insurance benefits to be paid directly to Nittany Valley Chiropractic and all doctors working within. I HAVE BEEN INFORMED OF THE MOST LIKELY COMPLICATIONS OR THE POSSIBLE UNDESIRABLE RESULTS OF CHIROPRACTIC EXAMINATION AND TREATMENT IN THIS OFFICE AND I UNDERSTAND THEM FULLY. I HEREBY AUTHORIZE AND DIRECT NITTANY VALLEY CHIROPRACTIC TO PROVIDE SUCH ADDITIONAL SERVICES AS THEY DEEM REASONABLE AND NECESSARY. I HEREBY SIGN THAT I HAVE READ THIS CONSENT, AND I UNDERSTAND, AND WILL COMPLY WITH MY RESPONSIBILITY FOR THE ABOVE POLICIES.

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

Signature


Finalizing Form



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