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
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Contact Information
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(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.)
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Draw Your Symptoms
Click on a crayon and draw on the body above to indicate your symptoms
Employment Information
Current Symptoms
If Yes, Explain:
If yes:
If Yes, Explain:
If Yes, Explain:
If Yes, Explain:
If Yes, Explain:
If Yes, Where?
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:
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:
For Women Only
COMPLETE THIS SECTION ONLY IF YOU ARE (OR THE PATIENT IS) A WOMAN OVER 16 YEARS OF AGE.
Health Problems & Concerns:
Please select all that you have had or currently have.
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
I consent to the collection and use of the above information by Chirofit Wellness Center and it's staff. I authorize this office and its staff to examine and treat my condition as the doctors see fit. If I move forward with treatments, I give my consent to be treated in an open adjustment room. I understand that it is my responsibility to make known any and all information about myself not excluding symptoms, injuries, mechanism, history, pathological defects, illnesses, and/or deformities that would not come to the attention of the doctor. I understand that I have the right, as a patient, to be informed about the condition of my health and the recommended care and treatment to be provided so that I may make the decision whether or not to undergo chiropractic care after being advised of the known benefits, risks and alternatives. I understand that all conditions respond differently to treatment and that occasionally, results are less than expected. I do understand that in the event my condition is not responsive that I may be referred to another health care specialist that works with our doctors to evaluate my health care regime.
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 this office is an out of network provider and does not submit claims to health insurance companies. 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.
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.
Name of the Insured:
(Please Print)
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_____________________________________________
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Patient's/Guardian's signature:
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_____________________________________________
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Date:
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__________
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Signature