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
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Personal Information
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Contact Information
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(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.)
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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.
Mechanism of Injury
The injury was due to: (choose one)
What date did the accident happen?
FOR WORKMAN'S COMPENSATION-RELATED VISITS ONLY: How did the injury occur? Choose all that apply.
As a pedestrian, what were you (or was the patient) doing at the time of the accident?
Where were you (or was the patient) looking at the time of impact?
Did you (or the patient) receive an injury to the head?
Did your (or the patient) lose consciousness?
What part of your (or the patient’s) vehicle was impacted? Choose all that apply.
In what direction was your (or the patient's) vehicle moving?
What was the estimated speed of your (or the patient’s) vehicle?
What was the extent of the damage to your (or the patient's) vehicle?
What was the extent of the damage to the other vehicle?
In what direction was the other vehicle moving?
What was the estimated speed of the other vehicle?
Was your (or the patient’s) vehicle towed from the scene?
Did police arrive at the scene?
Was an accident report taken?
Did Emergency Medical Services arrive at the scene?
Were you (or was the patient) transported to a medical facility (ER or hospital)?
Have you (or has the patient) received any treatment since the accident?
What was the location of symptoms felt at the time of the accident? Choose all that apply.
Head
Neck
Back
Trunk
Upper Extremity
Lower Extremity
Describe the discomfort felt at the time of the accident. Choose all that apply.
Are there any additional symptoms which appeared since the accident happened? Choose all that apply.
Describe the status of your symptoms since the accident. Choose all that apply.
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?
Which of the following medications are you presently taking? Choose all that apply.
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
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Click on a crayon and draw on the body above to indicate your symptoms
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
I certify that I'm the patient or legal guardian listed above. I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various models of physical therapy and diagnostic x-rays on me(or on the patient named below who I am legally responsible) by the doctors of chiropractic named below and/or other licensed doctors of chiropractic who now or in the future work at the clinic or office listed or any other office or clinic. I have had an opportunity to discuss with the doctor and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and other procedures. I understand results are not guaranteed. I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment, including but not limited to fractures, disc injuries, stroke, dislocations, and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known to him/ her is in my best interest. I have read, or have had read to me, the above consent. I have also had the opportunity to ask questions about its content, and by signing below I agree to the above named procedures. I intend this consent to cover the entire course of treatment for my present conditions and for future conditions for which I seek treatment. Kenny R. Sheppard, D.C. Annemarie Sheppard, D.C. Andrew Pierce, D.C. Chelsea Sheppard, D.C. Financial Policy We would like to explain our financial policy as customary with professional services. All services rendered are charged directly to you and you are personally responsible for payment. If you have any questions regarding financial matters please feel free to contact our staff. HIPPA Privacy PolicyThe health insurance portability and accountability act of 1996, or HIPPA allows the use of certain health information for the fallowing activities. Treatment: We may use or disclose your health information to a physician or other health care provider providing treatment to you. Payment: We may use disclose your health information to obtain payment for services we provide to you. Healthcare operations: We may use or disclose your health information in connection with our health care operations or when permitted by HIPPA. Healthcare operations include quality assessment and improvement activities, reviewing competence or qualifications of health care professionals, evaluating practitioner and provider performance, and other business operations. If our use or disclosure is not for one of the activities described above and is not otherwise permitted under HIPPA, we will ask you to complete a written authorization before we use or release your health information. When receiving service with us you will be able to decide whether we can discuss your health information with friends or family. Even if you provide us with written authorization, you may withdraw that authorization in writing, at any time to stop the future disclosure of your health information. HIPPA provides you the fallowing rights Restricting use/disclosure, requesting confidential communications, inspecting and obtaining copies of your health information, requesting a change in your health information, requesting an accounting of disclosure of your health information, obtaining notice of our privacy policy. If you believe that the privacy of your health information has been violated you may contact us to discuss your concern or file a complaint at 858-305-6290. or 634 Stevens Ave Solana Beach CA 92075. You may also file a complaint with the secretary of the US department of health. By signing this form, you consent to our use and disclosure of your protected health information as indicated above and in full length notice of privacy practices. Please note that your personal information is not shared with third parties and use is restricted to procedures that are relevant to your care.
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Name of the Insured:
(Please Print)
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_____________________________________________
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Patient's/Guardian's signature:
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_____________________________________________
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Date:
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__________
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Signature