Torrington Chiropractic
1063 E. Main St.
Torrington, CT 06790
888-800-8404

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

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

Insurance & Payment for Care


Primary Insurance
Secondary Insurance

If an auto accident, please provide:

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. 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. I grant the use of my signed statement of authorization with my signature for required insurance submissions. 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. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment. Appointment Calls, Open Room Adjusting & Health-Care Information:The entities and doctors listed at the bottom of this form (from this point on referred to as “our offices”) may need to use your name, address, phone number and your clinical records to contact you with appointment reminders, information about treatment alternatives or other health related information that may be of interest to you, If this contact is made by phone and you are not at home, a message will be left on your answering machine or with a family member. By signing this form, you are giving us authorization to contact you with these reminders and information.You can restrict the individuals or organization to which your health care information is released or you may revoke the authorization to us at anytime, however, your revocation must be in writing-and mailed to us at our office address. We will not be able to honor your revocation request if we have already released your health information before we receive your request to revoke your authorization. In addition, if you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims.Information that we use or disclose based on the authorization that you are giving us may be subject to re-disclosure by anyone who has access to the reminder or other information and may be no longer protected by the federal privacy rules.You have the right to refuse to give us this authorization. If you do not give us this authorization, it will not affect the treatment that we provide to you or the methods we use to obtain reimbursement for your care.By signing this, form, you authorize the release of your medical records from any medical provider, hospital, attorney, or insurance office to our offices. You in turn, authorize our offices to release information concerning your condition to any insurance company, attorney or adjuster in order to process any claim for reimbursement of charges incurred.We offer treatments in an open room style, with other patients in the same room. Occasionally comments about your symptoms, improvement or lack there of may be discussed at your office visits.We frequently show medical images and other results in the open room for our analysis and your understanding. If at any time you need privacy please let the doctor know and you will be given access to a private room.You may inspect or copy the information that we used to contact you to provide appointment reminders, information about treatment alternatives or other health related information at any time with notice.If I elect treatment I understand there is a slight risk of injury from an adjustment in patients where underlying pathologies may exist. This can include fractures, stroke, and other injuries.This notice is effective as of the date signed below, this authorization will expire seven years after the date in which you last received services from us,I authorize this office to use or disclose my health information in the manner described above. I understand that I may receive-a-copy of this form when needed.

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

Finalizing Form


  1. Submit Form!