Wood Chiropractic, Inc
150 Nellen Ave Suite 200
Suite 200
Corte Madera, CA 94925

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.





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



Head, Eyes, Ears, Nose and Throat






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.

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:


PLEASE READ CAREFULLY 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. HIPAA- 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.FINANCIAL- I understand and agree that all services rendered to me will be charged to me, and I'm responsible for payment of such services at the time of treatment. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself.• You will be required to pay for your care until coverage is verified. • All co-pays and deductibles are due at the time the services are rendered• I understand that I am ultimately responsible for my therapy charges even if the insurance company says you have coverage and they don’t pay.INFORMED CONSENT- In accordance with California law this notice is to inform you as a patient of the material risks of undergoing chiropractic care. Material risk means that there are known inherent risks of severe bodily injury from a particular treatment. Since the literature is vague and sometimes biased it is not absolutely known that there are any material risks from chiropractic care in general. Chiropractic has the lowest incidence of any reported side effects than any other healthcare profession. Evidenced by our extremely low malpractice rates. The procedures that will be performed in the course of your care, will consist of gentle chiropractic manual adjustments, soft tissue work, ART, Graston and light force instrument posture balancing. You may receive laser therapy, E-Stim, flexion distraction for low back and disc pain and also non surgical spinal decompression. As well as the terminator machine for muscle stiffness and adhesions.In the history of chiropractic, there has been an extremely rare rate of occurrence for muscle spasms, tightness, rib fracture, and disc injuries. Also, there have been medical reports of a possible connection to stroke although unconfirmed in the literature. In fact, there is an extremely rare rate of this happening from chiropractic treatment. The largest study was done in 2001 by the Canadian Medical Association Journal that said there is a 1 in 5.85 million risk that cervical manipulation performed by either an MD, PT, or DC would be followed by a stroke. The author David Cassidy, a professor of epidemiology at the University of Toronto said Patients had already damaged the artery before seeking help from either a medical doctor or a chiropractor and then the stroke occurred after the visit. You may experience some mild symptoms during the healing phase of your care. Please understand that these mild symptoms are normal and indicate healing as your health returns to its optimal state. Finally, there are risks of not getting prescribed chiropractic care. These were one of the components of risks from the Association of Chiropractic Colleges guidelines on informed consent from 2008. They include disc degeneration, loss of mobility, loss of tone, and decreased quality of life in the untreated spine. I acknowledge that I have discussed or have had the opportunity to discuss all possible risks and treatment with my chiropractor. My chiropractor has explained these risks to me verbally and in the contents of this form. My signature applies to any and all future and past treatments in this office.

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


Finalizing Form

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