Steve J Costales Chiropractic, Inc
24741 Alicia Pkwy Suite D
Suite D
Laguna Hills, CA 92653
949-951-1160

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.

Welcome to our office of chiropractic. Thank you for taking a moment to fill in our Patient Intake Form. Please fill this form completely and to the best of your knowledge. Let our staff know if you have any questions. When complete return it to our office with the bottom authorization checked and appropriate signatures filled in.

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

*First Name:
Middle Name:
*Last Name:
*Gender:	Female Male
*Date of Birth:
Social Security #:
Height:	Feet Inches
Weight:
Marital Status:
Spouse's Name:
Number of Children:

Emergency Contact:
Relationship:
Phone:

*Email:
	(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.)
*Home Phone:
Cell Phone:
Work Phone:

Country:
Address Line 1:
Address Line 2:
City:
State/Province/Region:
*Zip/Postal Code:

(Back to Top) | (Go to Submit)

Employment Information

Regular Work Status:
Employer Name:
Employer Address:
Employer City:
Employer State:
Employer Zip:
Occupation:
Supervisor Name:
Supervisor Phone/Extension:
Physical Work Duties:

(Back to Top) | (Go to Submit)

What is the purpose of your visit?

Wellness Complaint Injury Other

Current Symptoms

Where did the injury occur?

Automobile Work 3rd Party Premises Other

Date of Injury:

Please Describe how the injury, pain, or discomfort originated:

Please describe your pain/discomfort:

Select frequency you experience pain from this condition:

Always Hourly Daily Occasionally

Does this condition interfere with any of your daily activities or routines?

No Yes

Has this condition affected your quality of sleep or ability to sleep?

No Yes

Has this condition affected your appetite?

No Yes

If Yes, Explain:

Have you missed any work due to this injury?

No Yes

If yes:
Select unable to work from date:
Select day you have or will return to work:

Have you reduced or limited your work hours because of this condition?

No Yes

If Yes, Explain:

Is the pain/discomfort worse at certain times of the day?

No Yes

If Yes, Explain:

Does the weather affect your pain/discomfort?

No Yes

If Yes, Explain:

List anything that aggravates your condition:

List anything that relieves or improves your condition:

Have you received professional treatment for this condition?

No Yes

If Yes, Explain:

Have you had X-rays taken for this condition?

No Yes

If Yes, Where?

Pain level Rating - Scale 1 to 10 (Where 1 is least pain and 10 is maximum pain)

At its best: At its Worst: Current Level:

Have you ever had this same condition?

No Yes

If Yes, When?:

List other practitioners seen for this injury/condition:

(Back to Top) | (Go to Submit)

Personal Health History

Family/Primary Physician

Date of Last Physical Exam:
Name of Family Physician or Physician Seen:
Physician Phone:
Physician City:
Physician State:
Physician Zip:

Please list any health conditions that you have been treated for in the last year:
(condition, cause, current/resolved)

Separate details with "," comma as shown above.

Have you had previous chiropractic care?

No Yes

Condition(s) treated:

Date of last chiropractic visit:

Are you pregnant, or have you had any signs of pregnancy? (Female Only)

No Yes

Are you planning to get pregnant in the next 12 months? (Female Only)

No Yes

List current medications:
(name, amounts, frequency, length of use, reason for use)

Separate details with "," comma as shown above.

List current vitamins, minerals, supplements, or herbs:
(name, amounts, frequency, length of use, reason for use)

Separate details with "," comma as shown above.

(Back to Top) | (Go to Submit)

Family Health History

Please list diagnosed health conditions and untimely deaths.(condition, relationship to you)
(Family members include: Parents and siblings and maternal and paternal grandparents/aunts/uncles)

Separate details with "," comma as shown above.

(Example: arthritis, cancer, diabetes, heart disease, kidney disease, high cholesterol, etc.)

(Back to Top) | (Go to Submit)

Reason for this Visit

Describe the reason for this visit

Please briefly describe, including the impact it has had on your life.

If you're only here for chiropractic wellness services please skip this section.

Wellness Sports Auto Fall Home Injury Job Chronic Discomfort Other

Briefly Explain:

When did this concern begin?

Has this concern:

Gotten Worse Stayed Constant Come and Gone

Does this concern interfere with:

Work Sleep Daily Routine Other Activities

Briefly Explain:

Has this concern occured before?

Yes No

Briefly Explain:

Have you seen other doctors for this concern?

Yes No

Doctor's Name:

Type of Treatment:

Results: Good Bad Indifferent

(Back to Top) | (Go to Submit)

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.

I want the Doctor to select the type of care appropriate for my condition.

Relief care: Symptomatic relief of pain or discomfort.
Corrective care: Correcting and relieving the cause of the problem as well as the symptom.
Comprehensive care: Bring whatever is malfunctioning in the body to the highest state of health possible with Chiropractic care.

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. ASSIGNMENT OF BENEFITS: I hereby instruct my insurance company to pay by check and directly mail to: Steve Costales D.C., M.S., A.T.C. and/or Patricia McHone D.C. Chiropractic Sports Medicine 24741 Alicia Parkway Suite D Laguna Hills, CA 92653For professional/medical expense benefits allowable, and otherwise payable to me under my current insurance policy as payment toward the total chargers for professional services rendered. This is a direct assignment of my rights and benefits under this policy. This payment will not exceed my indebtedness to the above mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional fees for non-covered services and/or fees, over and above the insurance payment or as required by my insurance policy. I grant the use of my signed statement of authorization with my signature for required insurance submissions. A photocopy of this Assignment shall be considered as effective and valid as the original. 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. PAYMENT POLICY:It is the policy of Chiropractic Sports Medicine to receive payment in full at the time services are rendered unless other arrangements have been made in advance. 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 and enrollment is not a guarantee of payment. Deductibles, co-payments and patient responsibility amounts are due at the time of service. Our office does not assume responsibility for verification of benefits and/or coverage. Please contact your insurance company before services are rendered. Any portion of the balance not paid by the insurance company due to patient co-pays, deductible amount, non-covered services, services deemed not medically necessary, doctor non-participation in a plan or any other reason for non or reduced payment is the responsibility of the patient or responsible party. HMO’s and other insurance plans that require authorization for treatment from the Primary Care Physician or other source must send written authorization for treatment to our office prior to services being performed. Self referrals and out of network benefits are usually not covered. Authorization does not guarantee payment by the insurance company. A statement of charges will be sent to the patient/responsible party showing the patient due balance. Patient due balances over 60 days will be subject to late fees. Delinquent balances may be referred to an outside agency for collection. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment. I have read the above policy, and understand that I am financially responsible for all medical services rendered.

* I agree with this statement of authorization

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

Signature

Finalizing Form

Print Form (optional)
Submit Form!

Service provided by:

Patient Intake Form

Patient Information

Draw Your Symptoms

Employment Information

Current Symptoms

Personal Health History

Family Health History

Reason for this Visit

Goals for Your Care

Authorization

Signature

Finalizing Form