Wellness Experience
9180 Forest Hill Blvd.
Wellington, FL 33411
(561) 333-5351

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

Personal Information

Contact Information

*First Name:
Middle Name:
*Last Name:
*Gender:	Female Male
*Date of Birth:
Social Security #:
Height:	Feet Inches
Weight:
Marital Status:
Spouse's Name:
Number of Children:

Emergency Contact:
Relationship:
Phone:

*Email:
	(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.)
*Home Phone:
Cell Phone:
Work Phone:

Country:
Address Line 1:
Address Line 2:
City:
State/Province/Region:
*Zip/Postal Code:

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Draw Your Symptoms

Click on a crayon and draw on the body above to indicate your symptoms

How did you find out about our office?

Referring Physician:
Referring Patient:
Referred by:

Did you hear about our office from an advertisement?

No Yes

If Yes, Where:

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

No Yes

If Yes, Where:

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Employment Information

Regular Work Status:
Employer Name:
Employer Address:
Employer City:
Employer State:
Employer Zip:
Occupation:
Supervisor Name:
Supervisor Phone/Extension:
Physical Work Duties:

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What is the purpose of your visit?

Wellness Complaint Injury Other

Current Symptoms

Where did the injury occur?

Automobile Work 3rd Party Premises Other

Date of Injury:

Please Describe how the injury, pain, or discomfort originated:

Please describe your pain/discomfort:

Select frequency you experience pain from this condition:

Always Hourly Daily Occasionally

Does this condition interfere with any of your daily activities or routines?

No Yes

Has this condition affected your quality of sleep or ability to sleep?

No Yes

Has this condition affected your appetite?

No Yes

If Yes, Explain:

Have you missed any work due to this injury?

No Yes

If yes:
Select unable to work from date:
Select day you have or will return to work:

Have you reduced or limited your work hours because of this condition?

No Yes

If Yes, Explain:

Is the pain/discomfort worse at certain times of the day?

No Yes

If Yes, Explain:

Does the weather affect your pain/discomfort?

No Yes

If Yes, Explain:

List anything that aggravates your condition:

List anything that relieves or improves your condition:

Have you received professional treatment for this condition?

No Yes

If Yes, Explain:

Have you had X-rays taken for this condition?

No Yes

If Yes, Where?

Pain level Rating - Scale 1 to 10 (Where 1 is least pain and 10 is maximum pain)

At its best: At its Worst: Current Level:

Have you ever had this same condition?

No Yes

If Yes, When?:

List other practitioners seen for this injury/condition:

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Insurance & Payment for Care

How do you plan to pay for care?

Personal Insurance Third-Party Insurance No Insurance, Self-Pay

Name of Party Responsible for Payment:
Responsible Party Phone:

Primary Insurance

Secondary Insurance

Insurance Name:
Phone:
Address:
City:
State:
Zip:
ID/Policy #:
Group #:
Insured's Name:
Insured's Date of Birth:

Insurance Name:
Phone:
Address:
City:
State:
Zip:
ID/Policy #:
Group #:
Insured's Name:
Insured's Date of Birth:

If an auto accident, please provide:

Claim #:
Insurance Contact Person:
Insurance Phone:
Attorney's Full Name:
Attorney's Phone:

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Personal Health History

Family/Primary Physician

Date of Last Physical Exam:
Name of Family Physician or Physician Seen:
Physician Phone:
Physician City:
Physician State:
Physician Zip:

Please list any health conditions that you have been treated for in the last year:
(condition, cause, current/resolved)

Separate details with "," comma as shown above.

Have you had previous chiropractic care?

No Yes

Condition(s) treated:

Date of last chiropractic visit:

Are you pregnant, or have you had any signs of pregnancy? (Female Only)

No Yes

Are you planning to get pregnant in the next 12 months? (Female Only)

No Yes

List current medications:
(name, amounts, frequency, length of use, reason for use)

Separate details with "," comma as shown above.

List current vitamins, minerals, supplements, or herbs:
(name, amounts, frequency, length of use, reason for use)

Separate details with "," comma as shown above.

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Family Health History

Please list diagnosed health conditions and untimely deaths.(condition, relationship to you)
(Family members include: Parents and siblings and maternal and paternal grandparents/aunts/uncles)

Separate details with "," comma as shown above.

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

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Social History & Life Choices:

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Chiropractic Experience

Who referred you to our office?

Where did you hear about us?…

Please select all that apply.

Newspaper Sign Yellow Pages Community Event Mailing Other

Other:

Have you been adjusted by a chiropractor before?

Yes No

If yes…

What was the reason for those visits?

Doctor's Name:

Approximate date of last visit:

Has any member of your family ever seen a wellness chiropractor?

Yes No

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Reason for this Visit

Describe the reason for this visit

Please briefly describe, including the impact it has had on your life.

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

Wellness Sports Auto Fall Home Injury Job Chronic Discomfort Other

Briefly Explain:

When did this concern begin?

Has this concern:

Gotten Worse Stayed Constant Come and Gone

Does this concern interfere with:

Work Sleep Daily Routine Other Activities

Briefly Explain:

Has this concern occured before?

Yes No

Briefly Explain:

Have you seen other doctors for this concern?

Yes No

Doctor's Name:

Type of Treatment:

Results: Good Bad Indifferent

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Auto Accident

Date & Time: Make & Model:
Street / Location: # of persons in your vehicle
Were you the: Were you:
Speed of your vehicle: Speed of their vehicle:
Were you wearing a seat belt?YesNo Have you worked since this injury?YesNo
Are your work activities restricted?YesNo Were there any witnesses?YesNo
Did the vehicle have airbags?YesNo Did the airbags inflate?YesNo
Did the police arrive?YesNo Police report filed?YesNo

Visited a Hospital or Doctor?

YesNo Name of hospital:
When did you go to the hospital?
How did you get to the hospital?
Was the Doctor a?
Were any X-rays taken?YesNo
Medication prescribed?YesNo

Were you rendered unconscious?

YesNo How long?

Traffic violation issued?

YesNo To Whom?

Retained an attorney?

YesNo Name: Phone:

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?

Explain:

Strike anything in the vehicle?

Explain:

Describe the accident?

How did you feel right after?

Names of all persons in this accident:

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Authorization

I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read them or declined the opportunity to read them and understand the Notice of Privacy Practices. I understand that this form will be placed in my patient chart and maintained for six years.Private pay patients are expected to provide payment in full at the time of service. We accept cash, check and all major credit cards. We also require a copy of your driver's license. Patients using general insurance are required to fill out a confidential form as well as provide us with your driver's license and insurance card on the first visit. If you do not provide your insurance information within 5 business days of your first visit, you will be switched to a private pay plan. We will call the insurance company to verify your benefits, however, that does not guarantee payment for services that are provided. We will bill your insurance as a courtesy. You are responsible for all deductibles, co-payments and non-covered services at the time services are rendered.If you have been involved in an auto accident, we require a copy of your accident report, auto insurance and all health insurance information. If an attorney is involved, you must return a signed doctor's lien form within 7 business days of your first visit. All accident patients must seek medical treatment within a 14 day period from the date of the accident. Non-emergency chiropractic visits are subject to a $2,500 limit. Emergency chiropractic visits are subject tot a $10,000 limit. If no treatment has been rendered within a 14 day period, you are responsible for full payment.Dr. Randall Laurich is a participating Medicare provider which means we submit your claims to Medicare. Medicare patients are subjected to a $183.00 yearly deductible that must be met before your co-insurance will be applied. Once the deductible is met, Medicare will pay 80% of the allowable fee and you are responsible for 20% of the associated fees unless you have a secondary insurance. The spinal adjustment is the only covered service under Medicare. Maintenance care is not covered by Medicare, nor are the required exam fee of $35.00. Any non-covered service must be paid for at the time of service.Please be aware that any patient account 31 days past due will accrue all responsible collection costs and/or attorney fees. All accounts will be assessed 1.5% per month on the outstanding balance from the date of service. I understand that there is no guarantee that insurance companies, prepaid heath plans or Medicare will cover or pay for all of my charges. I understand that I am responsible for all remaining charges.We require that all massage patients must make any massage cancellations 24 hours prior to their scheduled appointment. Cancellations made within that 24 hour window are subject to a $35.00 cancellation fee.

* I agree with this statement of authorization

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

Signature

Finalizing Form

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Service provided by:

Alcohol Daily Weekly Occasionally Never	Caffeine Drinks & Products Daily Weekly Occasionally Never
Diet Food Products Daily Weekly Occasionally Never	Drugs Daily Weekly Occasionally Never
Energy Products or Over-the-Counter Stimulants Daily Weekly Occasionally Never	Exercise Daily Weekly Occasionally Never
Fresh & Homemade Foods Daily Weekly Occasionally Never	Preprocessed, Packaged, & Restaurant Food Daily Weekly Occasionally Never
Soft Drinks Daily Weekly Occasionally Never	Tobacco Daily Weekly Occasionally Never
Water Daily Weekly Occasionally Never