Storey Chiropractic Clinic, P.C.
50 Broadway
Boise, ID 83702

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.





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?

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.

Employment Information


RESPONSIBLITY OF PAYMENT, CONSENT FOR EXAMINATION AND TREATMENT AND RISK OF TREATMENT. I understand and agree that health and accident insurance policies are an arrangement between and insurance carrier and myself. Furthermore, I understand that the Doctor’s office will prepare necessary reports and forms to assist me in making collection from the insurance and that any amount authorized to be paid directly to the Doctor’s office will be credited to my account on receipt. However. I clearly understand that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care at this office, any outstanding charges for professional services offered me will be immediately due and payable.I hereby request and consent to performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and , if necessary, diagnostic x-rays, on me by the doctor of chiropractic and/or anyone working in the clinic authorized by the doctor of chiropractic.I have had an opportunity to discuss with the doctor of chiropractic/staff member and/or staff member and/or with office or clinic personnel, the nature and purpose of chiropractic adjustments and other procedures. I understand that results are not guaranteed.I further understand and am informed that, as in all healthcare, in practice of chiropractic there are some very slight risks to treatment, including, but not limited to, muscle strains, sprains, rib fractures, disc injuries, and strokes. I do not expect the doctor to be able to anticipate and explain all the risks and complications and I wish to rely on the doctor to exercise judgement during the course of the procedure that the doctor fells at the time, based upon facts then known, and is in my best interests.I have read and understand the above and I consent to all examinations and care as deemed appropriate by the Doctor of Chiropractic for my present condition, and future conditions for which I may seek care. I realize that I may ask any questions to the doctor of chiropractic either before or after I sign this consent, and I understand that my consent can be withdrawn at any time.ASSIGNMENT OF BENNEFITS & MEDICAL RELEASEI hereby authorize payments to be made directly to the Storey Chiropractic Clinic (“Clinic”) for any and all such sums as may be due and owing for services rendered to me by Clinic. Further, I authorize the withholding of any sums as may be due and owing form any disability benefits, medical payment benefits, no-fault benefits, health and accident benefits, or any other type of available insurance benefits, as well as proceeds arising from settlement, judgement or verdict rendered in my favor, in order that such sums may be paid directly to the Clinic. Further, I assign to the Clinic any and all rights, claims of action I may have against any insurance company, to include my own, arising from the recovery of benefits for payment of services provided to me by the Clinic. In event that payment by insurance company is refused upon demand by either myself or the Clinic, I authorize the Clinic to compromise, settle or otherwise resolve any claim or cause of action which I may have against the insurance company. I understand and agree that I remain personally responsible for the total due and owing for services provided to me by the Clinic, to include any such amount as may remain due and owing following such compromise, settlement or resolution of insurance benefits. I permit this office to endorse co-issued remittances for the conveyance of credit to my account.I understand and agree that payment for services provided to me by the Clinic are due and owing immediately upon the rendering of such services. I understand and agree that if payment for such services is not made when due and owing, the Clinic may file a lien for reasonable charges for services against any and all causes of action, suits claims, counterclaims or demands accruing to me or my legal representative, on account of the injuries given rise to such causes of action and for which treatment was rendered. I understand and agree that the Clinic may demand that payments for Clinic services provided to me be kept current, and that any amount due and owing for more than thirty (30) days shall accrue interest at the rate of three percent (3.0%) per month until pain in full. This document authorizes Storey Chiropractic Clinic, P.C. to release medical information and reports as deemed necessary by the physician to my insurance company and/or attorney.I certify that I’m the patient or legal guardian._________________________________________________________Date________________________Signature of Patient_________________Initial of office witness

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

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