Ultimate Health Chiropractic
1035 Emmorton Rd
Bel Air, MD 21014
(410) 569-5969

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.

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.We are privileged that you are entrusting us with your healthcare. We are dedicated to providing the best possible care for you, and want you to completely understand our financial policies. In exchange for providing you with healthcare serivces, you, the patient, are ultimately responsible for paying for any services rendered by Ultimate Health. Acceptable forms of payment include: cash, personal check, money order, Visa, MasterCard, Discover or American Express. Due to rising administrative costs, patients will be billed a $10 fee for any co-payments not paid at the time of service. Patient accounts will be charged a fee of $30 for any returned checks for insufficient funds. Payment on any Statement of Account invoices mailed by Ultimate Health to you is due 21 days from the Statement date on the top of the Statement of Account. Any amounts not paid may be referred to a collection agency or to an attorney for collection. All accounts referred for collection will be charged interest in an amount equal to 2% per month, as well as court costs and private process server fees. An additional fee of 30% of the total amount owed will be assessed for accounts referred to a collection agency or an attorney. IN THE EVENT LEGAL PROCEEDINGS ARE COMMENCED TO RECOVER DELINQUENT ACCOUNTS, YOU HEREBY NOW AND FOREVER CONSENT TO JURISDICTION IN THE DISTRICT COURTS OF HARFORD COUNTY, MARYLAND. We understand that your time is valuable, so we will make every effort to be on time. Our time is also valuable, so we expect you to keep your appointment. If you are unable to keep your appointment, we require 24-hours advance notice. Because of time blocked off for appointments, cancellations/missed appointments after this time will result in a $25 charge to your account.

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

Signature


Finalizing Form



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