Shelby Chiropractic Health Center, Inc
679 N Vandemark Rd
Sidney, OH 45365
937-497-8779

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

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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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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Personal Incident History:

Broken Bones?

No Yes

If yes:
Did you get professional care/treatment?
No Yes

Briefly Explain:

Had Major Sprains/Strains?

No Yes

If yes:
Did you get professional care/treatment?
No Yes

Briefly Explain:

Been Hospitalized?

No Yes

Briefly Explain:

Had Surgery?

No Yes

Briefly Explain:

Been In Auto Accident?

No Yes

If yes:
Did you get professional care/treatment?
No Yes

Briefly Explain:

Been Struck Unconscious?

No Yes

If yes:
Did you get professional care/treatment?
No Yes

Briefly Explain:

Been Diagnosed with an Eating Disorder?

No Yes

Briefly Explain:

Had a Stroke?

No Yes

Briefly Explain:

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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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For Women Only

COMPLETE THIS SECTION ONLY IF YOU ARE (OR THE PATIENT IS) A WOMAN OVER 16 YEARS OF AGE.

Are you pregnant?

No Yes

Are you nursing?

No Yes

Are you taking birth control?

No Yes

Do you experience painful periods?

No Yes

Do you have irregular cycles?

No Yes

Do you have breast implants?

No Yes

Do you perform a regular self breast examination?

No Yes

Do you take hormone replacement therapy (HRT)?

No Yes

Do you take oral contraceptives?

No Yes

Estimate the date of your most recent PAP/pelvic exam:

Date of last mammogram?

Date of Last Menstrual Period?

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Health Problems & Concerns:

Please select all that you have had or currently have.

Other:

Have you had any of these Cardiovascular Diseases? Please select all that apply.

Myocardial infarction Hypertension Hypercholesterolemia Bypass surgery
Coronary artery disease

Do you have Diabetes? If so what type?

Type I Type II Juvenile

Do you have any stomach/digestive issues? Please select all that apply.

Ulcers Reflux IBS

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Electronic Health Record (EHR) Information

Preferred Language:

Ethnicity:

Race:

Smoking Status:

Smoking Start Date:

Type of Tobacco:

Cigarettes Chewing Tobacco Cigar Pipe Other

Have you tried to quit?

Yes No 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

I choose to decline receipt of my clinical summary after every visit (These summaries are often blank as a result of the nature and frequency of chiropractic care.)

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Authorization

I hereby request and consent to the performance of chiropractic treatments and procedures. I understand and am informed that, as with any medical treatment, chiropractic presents some risks including, but not limited to, fractures, disk injuries, strokes, dislocations and sprains/strains. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the treatment and/or procedure which the doctor feels at the time, based upon the facts then known, is in my best interest. Furthermore, I certify that I have read and understand the above information and that the above information is correct to the best of my knowledge. I understand that providing incorrect information can be dangerous to my health and may delay my recovery or prolong my treatment.I authorize the doctor to release any information including the diagnosis and records on any treatment and/or procedure rendered to me or my dependent during the period of such chiropractic care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the chiropractic office any and all insurance benefits otherwise payable to me. I agree to sign an Assignment of Benefits if asked. I understand that my insurance carrier may pay less than the actual fee for services. I agree to be responsible for payment of all services rendered on my behalf or the behalf of my dependant.

* I agree with this statement of authorization

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

Finalizing Form

Print Form (optional)
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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

Patient Intake Form

Patient Information

Draw Your Symptoms

Employment Information

Current Symptoms

Personal Health History

Personal Incident History:

Family Health History

Social History & Life Choices:

For Women Only

Health Problems & Concerns:

Electronic Health Record (EHR) Information

Authorization

Signature

Finalizing Form