Wisdom of Wellness Chiropractic Center
694 Orchard Lane
Roseburg, OR 97471
541-673-3276

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:

Electronic Health Record (EHR) Information


Preferred Language: Ethnicity:
Race:
Smoking Status: Smoking Start Date:
Type of Tobacco:
Have you tried to quit? How much tobacco do you use?
How long have you used tobacco?
Current Medications And Dosage:
Medication Name Dosage
Medication Allergies:
Medication Name Reaction Date Discovered

Authorization

PATIENT INFORMED CONSENT FORM BELOW WILL BE PRINTED AND SIGNED IN OUR OFFICE ___INITIAL-- I, the undersigned, hereby request and consent to the performance of chiropractic adjustments and procedures, including various modes of physiotherapy modalities and physiological therapeutics (i.e. vitamin/mineral supplementation, botanicals, homeopathic preparations, etc.) on me (or patient named above, for whom I am legally responsible), by Dr. Lauren Schroeder, D.C., and/or her relief doctor, or staff who now or in the future treat me in this office. ___INITIAL-- I understand that, as in the practice of any medicine, there are rare risks to chiropractic treatments, including but not limited to sprain/strains, fractures, strokes, general aggravations of inflammatory conditions, nutrient-drug and nutrient-nutrient interactions. I understand that I will have an opportunity to discuss with the doctor the nature or purpose of all procedures. I understand that the doctor will perform an exam in order to minimize any risks; however, I do not expect the doctor to be able to anticipate and explain all risks/complications. I therefore wish to rely on the doctor to exercise professional judgment during the course of procedures which the doctor feels at the time, based upon facts as then known, is in my best interests. Finally I understand that Dr. Lauren Schroeder, D.C., gives no guarantee or assurance as to the results of her procedures. ___INITIAL-- In the event the undersigned has a dispute about the quality of service that cannot be resolved directly with Dr. Schroeder about her or her staff, the undersigned agrees to submit the dispute to arbitration, according to Title 3, Sections 36.310 et seq. of the Remedial Code, Oregon Rules of Civil Procedure, before a neutral arbitrator to be selected by the parties or appointed by the court. Arbitration shall occur in Douglas County, Oregon, may be compelled by petition of either party to the court, and any award resulting from such arbitration shall become binding on the parties, upon confirmation by the court. This Arbitration clause shall not prevent Dr. Lauren Schroeder, D.C., from taking any action to collect a debt owed by the undersigned. In the event of arbitration/litigation, the prevailing party shall recover reasonable attorney fees from the adverse party. NOTICE TO PATIENTS WITH INSURANCE/ASSIGNMENT OF INSURANCE BENEFITS ___INITIAL-- INSURANCE IS NOT A GUARANTEE OF PAYMENT. As a service to me, this office agrees to bill my insurance. I, the undersigned, understand all expenses incurred for services rendered are solely my responsibility. Any denials for services rendered are between me and my insurance company, and I understand that I am fully responsible to pay for these denied/ uncovered services within 60 days of receipt of a statement and resolve the discrepancies directly with my insurance. I also understand that I am responsible for any collection agency, attorney and court fees involved in the collection of this account. ___INITIAL-- The undersigned authorizes Dr. Lauren Schroeder, to furnish my third party payer all relevant information which may be requested regarding my claim to determine eligibility, benefits, diagnosis and review of health care services for medical necessity, and I release Dr. Lauren Schroeder from any liability for furnishing/acquiring such information. I assign all payments to Dr. Schroeder for which I am entitled for expenses related to the services performed, but not to exceed my indebtedness to this office. Any money received after my account is paid in full, will be refunded to me. If insurance payments, intended for treatment by Dr. Schroeder, are sent directly to me, it is my responsibility to pay her office within 7 days. If she is not a preferred provider with my insurance company, I am fully responsible for services rendered above what the insurance allows. ___INITIAL-- MEDICARE: I understand that Medicare pays 80% for spinal manipulations only and I am responsible for the remaining 20% and ALL other services performed, by my consent, that are not covered/denied by Medicare and I am responsible for these in full at the time services are rendered, unless payment arrangements have been made in advance. This office has agreed to bill Medicare. I understand that any denials for services rendered is between me and Medicare, and it is my responsibility to pay this office for these denied services and resolve the discrepancies directly with my insurance(s). RIGHT TO REVOKE ___INITIAL-- You have the right to revoke this consent at any time by giving us written notice of your revocation submitted to the contact persons listed above. Please understand that revocation of the Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you, should you revoke this Consent.I have read or have had read to me, the above consent and privacy practices. I have also had an opportunity to ask questions about it, and by signing below I agree to Dr. Schroeder’s office practices. I intend this consent form to cover the entire course of treatment for my present and any future condition(s) for which I seek treatment. Dr. Schroeder’s office reserves the right to change these privacy practices. If they change their practices, they will issue a revised Notice. Any changes may apply to any of my protected health information that they maintain. At any time I am entitled to a copy of this consent after I sign it or any future revised notices by contacting this office in writing at the above address. DATE:__________________ Patient/Responsible Party signature:______________________________ Print Name:__________________________________________________ Relationship to Patient: Self/ Parent/ Guardian

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

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