ProAdjuster Chiropractic Clinic at Virginia Beach
525 S. Independence Blvd 190
Virginia Beach, VA 23452
(757) 473-9900

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

Employment Information


Insurance & Payment for Care


Primary Insurance
Secondary Insurance

If an auto accident, please provide:

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:

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 hereby assign all applicable health insurance benefits to which I and/or my dependents are entitled to Provider. I certify that the health insurance information that I provided to Provider is accurate as of the date set forth below and that I am responsible for keeping it updated.I hereby authorize Provider to submit claims, on my and/or my dependent’s behalf, to the benefit plan (or its administrator) listed on the current insurance card I provided to Provider, in good faith. I also hereby instruct my benefit plan (or its administrator) to pay Provider directly for services rendered to me or my dependents. To the extent that my current policy prohibits direct payment to Provider, I hereby instruct and direct my benefit plan (or its administrator) to provide documentation stating such non-assignment to myself and Provider upon request. Upon proof of such non-assignment, I instruct my benefit plan (or its administrator) to make out the check to me and mail it directly to Provider.I am fully aware that having health insurance does not absolve me of my responsibility to ensure that my bills for professional services from Provider are paid in full. I also understand that I am responsible for all amounts not covered by my health insurance, including co-payments, co-insurance, and deductibles.I understand and agree that health and accident insurance policies are an arrangement between my insurance carrier and myself. Furthermore, I understand that the Chiropractic Center of Virginia Beach will prepare any necessary reports and forms to assist me in making collection from my insurance company and that amount authorized to be paid directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate treatment, fees for professional services rendered to me will immediately be due and payable.Should the undersigned default under their terms, and this account referred to an attorney for collection, then the undersigned promise and agrees to pay attorney fees of 33.5% of the principle amount due and owing when turned over for collection and does further agree to pay interest on the unpaid balance at the rate of 1.5% per month (18% per annum) from the date that said monies became due and payable.I hereby authorize the Chiropractic Center of Virginia Beach to examine and treat my condition as deemed appropriate. The patient also agrees that she/he is responsible for all bills incurred at this office. In the event this matter is turned over for collection, I hereby expressly give permission for my current employer(s) to provide verification of my said employment to this office, or their attorney, Bischoff Martingayle, PC. Notice of Privacy PracticesIn accordance with the Protected Health Information Act (PHI) our office will, without asking your express consent or authorization, use and disclose your PHI for the purposes of:TreatmentPaymentHealth Care OptionsAdvice of Appointments and ServicesDirectory/Sign-In LogCourt Orders, Subpoenas and Government InvestigationsAdvise Family/ Friends directed by you to receive information regarding your health or to assist in the payment of your bill.You have the right to revoke, request special limits or conditions, to receive communication by more confidential means or at alternate locations, to inspect and copy your PHI, and to amend your PHI. Our office strives to maintain HIPAA compliance. I understand that by signing the above statement I have been notified of my rights in compliance with HIPPA regulations. I have been advised that I may request a complete copy of these rights available through the HIPAA officer at this location.Authorization to Release InformationI hereby authorize Provider to: (1) release any information necessary to my health benefit plan (or its administrator) regarding my illness and treatments; (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature to be used to process insurance claims. This order will remain in effect until revoked by me in writing.ERISA AuthorizationI hereby designate, authorize, and convey to Provider to the full extent permissible under law and under any applicable insurance policy and/or employee health care benefit plan, as my Authorized Representative: (1) the right and ability to act on my behalf in connection with any claim, right, or cause in action that I may have under such insurance policy and/or benefit plan; and (2) the right and ability to act on my behalf to pursue such claim, right, or cause of action in connection with said insurance policy and/or benefit plan (including but not limited to, the right to act on my behalf in respect to a benefit plan governed by the provisions of ERISA as provided in 29 C.F.R. §2560.5031(b)(4)) with respect to any healthcare expense incurred as a result of the services I received from Provider and, to the extent permissible under the law, to claim on my behalf, such benefits, claims, or reimbursement, and any other applicable remedy, including fines.A photocopy of this Assignment/Authorization shall be as effective and valid as the original.By signing below, I give my consent for examination and the performance any tests or procedures needed. If patient is a minor, by signing I give consent for examination, tests and procedures for the above minor patient.Appointment PolicyWE RESPECT YOUR TIME AND YOUR BUSY LIFE!!! Our office sees over 98% of our patients on time. If you are running late, ie (stuck in traffic) please call the office. If you are running more that 10 minutes late we probably will not be able to see you. I understand that if I miss an appointment without calling, I will be charged a $35.00 service fee.

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

Signature


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