Steele Chiropractic, Inc.
46 East Main Street N.
Hampton, GA 30228
770-946-4075

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.

Standard Pediatric Evaluation


Is there a history of any problems that the doctor should know about? Choose all that apply.
How was the baby delivered?
Were forceps used in the delivery process?
Was vacuum extraction used in the delivery process?
How many hours was the labor?
How long was the pushing (in minutes)?
Was this a single or multiple birth?
What was the birth weight (pounds)?
lbs.
What was the birth weight (ounces)?
oz.
What was the length of the child at birth (inches)?
inches in length
What was the total APGAR score (5 minutes after birth, 10 is perfect)?
At how many weeks was the child born (gestational age in weeks)?
 weeks
Which vaccines has the child had to date? Choose all that apply. If all vaccination are up to date, select "Received all childhood vaccinations."

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.

Social History & Life Choices:


 

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:

Authorization

Consent for Treatment and/or X-rays: I certify that I am the Legal Parent/Guardian of the minor child listed above. OR I certify that I am the patient listed above. I do hereby authorize, request and direct the Clinic shown above, its doctors and staff to perform examinations, diagnostic x-rays and any treatment that, in their judgment, is deemed advisable and required. I do hereby release STEELE CHIROPRACTIC, INC. and TIMOTHY N. STEELE, D.C. from any and all liability. Said Clinic will not be held responsible for any pre-existing medically diagnosed conditions nor any medical diagnosis. Guarantee of Payment: I understand that I am fully responsible for any fees incurred related to my treatment (or the treatment of my minor child) and that payment is due at the time of service. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable. Certification: I have read/understand the included information and certify it to be true and accurate to the best of my knowledge.

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

Signature


Finalizing Form



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