The Healing Touch Chiropractic Clinic, LLC
320 Liberty Street SE
Salem, OR 97301
503-371-1120

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.)

   

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

How did you find out about our office?


Did you hear about our office from an advertisement?

If Yes, Where:

Did you hear about our office from a phone or professional directory?

If Yes, Where:

Employment Information


Current Symptoms


If Yes, Explain:

If yes:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Where?




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.

Personal Incident History:


If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

Family Health History


Separate details with "," comma as shown above.

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

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:

Reason for this Visit

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

Does this concern interfere with:





Results:

For Women Only

COMPLETE THIS SECTION ONLY IF YOU ARE (OR THE PATIENT IS) A WOMAN OVER 16 YEARS OF AGE.

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.




Were You Aware That...

Health Problems & Concerns:


Please select all that you have had or currently have.

Worker's Compensation







Describe the accident?

Do you lift from?

Do you have to reach?
Is your work area cluttered?
Do you push or pull?
Do you pick up or lift?

Do you lift in and out of a machine?
Type of Floor:

Type of ventilation:

Type of lighting:

Is your work area:

Do you have any other jobs?
Has outside help been hired?
Do you use a cart?



Auto Accident










Visited a Hospital or Doctor?






Were you rendered unconscious?
Traffic violation issued?
Retained an attorney?

In relation to the base of your skull, where was the headrest?

Impact to your vehicle came from?

The direction you were heading?
The direction they were heading?

The direction you were facing?
What did your vehicle impact?

Strike anything in the vehicle?

Describe the accident?

How did you feel right after?

Names of all persons in this accident:

Authorization

Financial Policy (If you choose not to read this – it is still in effect) Insurance estimates are based on information provided by your insurance company. The amount of insurance coverage estimated is an estimate only, and may not reflect what your insurance carrier will actually pay. Please understand: 1. Your health insurance is a contract between you and your insurance provider and may involve your employer. We are not a part of that contract. 2. Not every service we provide may be a benefit with all insurance companies. 3. The patient understands that they are ultimately responsible for treatment costs, not covered by insurance. Please be advised: We offer a 15% discount for payment at time of service on all services. Patient Agreement: I hereby assign Dr. Zohra Campbell-Bolduc/The Healing Touch Chiropractic, the insurance benefits that are otherwise payable to me for her charges and direct said insurance payments to be made directly to her. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not I have insurance. I hereby authorize assignee to release all information necessary to secure payment. HIPPA Privacy Practice (If you choose not to read this – it is still in effect) We are required by law to maintain the privacy of and provide individuals with a notice of our legal duties and privacy practice w/ respect to protected health information. If you have any objection to this form please ask to speak with our HIPPA compliance officer in person or by phone at our main number. Signature below is only an acknowledgement that we have offered you the notice of or privacy practices. Consent of treatment: Chiropractic examination and therapeutic procedures (including spinal adjustments, ultrasound, heat application, and manual muscle therapy) are considered safe and effective methods of care. Occasionally complications may arise. While the chances of experiencing complications are small, it is the practice of Healing Touch Chiropractic to inform our patients about them. Side effects may include, not limited to, soreness, inflammation, soft tissue injury, dizziness, burns and temporary worsening of symptoms. More serious complications include injury to the arteries in the neck, which may be associated w/ stroke or serious neurological impairment, injury to the spinal discs, and spinal fractures. Serious complications are estimated to be in the range of 2-5 incidents per million adjustments for adjustments of the neck, and 1 per million for adjustments to the low back. Additional information on side effects, complications and effectiveness of spinal adjustments are available upon request.Medicare Notice of Non Coverage (ABN) Insurance does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect insurance may not pay for some of the services we provide.o Option 1 – I would like to continue my treatment at this office. I understand that not all services provided will be covered by my insurance and I am willing to pay for what is not covered.o Option 2 – I would like to continue my treatments at this office. I do not want to bill my insurance and I will pay for the services I have incurred out of pocket.We break down our services and the cost of each treatment in our menu of services. If you have any questions on what services will be covered under your insurance plan, you may call the number on the back of your insurance card or in your insurance hand book.Signing this form tells us you have received and understand the notices.

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

Signature


Finalizing Form


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