ADULT CHIROPRACTIC INTAKE FORM
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- Milo Collins
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1 ADULT CHIROPRACTIC INTAKE FORM Welcome to our office! It is well known that families who maintain strong, healthy, wellaligned spines have greatly improved health. People whose spines are not healthy and kept in proper alignment are much more likely to develop serious health challenges later in life. MY PURPOSE FOR TODAY S APPOINTMENT IS: (check all that apply to you) I m here for an evaluation. I m a healthy person and I m interested in maximizing my health and preventing future problems. I m here for an evaluation because I m having health challenges and am looking for a natural health solution. I m here for an evaluation. I am curious to know if my spine is healthy and to see if I have any problems that I don t know about. I am here for an evaluation because I m curious to learn more about Chiropractic Care I am here for an evaluation only Other IF THE DOCTOR FEELS THAT HE CAN HELP YOU: (Please check the one that best applies to you) I am willing to follow the doctor s recommendations because I strongly value my health. I am willing to receive care if payment plans are available. I am willing to receive care but only if my insurance pays for all of it. I am not interested in receiving any future care.
2 TERMS OF ACCEPTANCE FOR CHIROPRACTIC HEALTH CARE When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective. Chiropractic has only one goal: to eliminate misalignments within the spinal column, which interfere with the expression of the body's natural wisdom. It is important that each patient understand both the objective and the method that will be used to attain our goal. This will prevent any confusion or disappointment Adjustment: An adjustment is the specific application of forces to facilitate the body's correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine. Health: A state of optimal physical, mental and social well-being, not merely the absence of infirmity. Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses resulting in a lessening of the body's natural ability to express its maximum health potential. We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic examination, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis, or treatment for those findings, we will recommend that you seek the services of a health care provider that specializes in that area. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body's natural wisdom. Our only method of achieving this is through specific adjusting to correct vertebral subluxations. I, have read and fully understand the above statements. (print name) All questions regarding the doctor's objectives to my care in this office have been answered to my complete satisfaction. Signature Consent to Treatment of Minor Child I hereby authorize Cadence Chiropractic to administer treatment as they so deem necessary to my daughter / son / other, (name). Signature: : Witness: :
3 Whom may we thank for referring you to this office? Today s : PATIENT DEMOGRAPHICS NEW PATIENT HEALTH HISTORY Name: Birth : - - Age: File #: o Male o Female Address: City: State: Zip: Address: Home Phone: Mobile Phone: Marital Status: Single Married Do you have Insurance: Yes No Work Phone: Social Security #: Driver s License #: Employer: Occupation: Spouse s Name Spouse s Employer Number of children and ages: Name & Number of Emergency Contact: Relationship: HISTORY of COMPLAINT Please list your health concerns below: Health Concern in order of severity Rate Severity: 1 = mild 10 = unbearable Have you had the condition before? When? Did the problem begin with an injury? Are symptoms constant or intermittent? Have you ever seen other doctors for these conditions? Chiropractor? Y / N Medical Doctor? Y / N Other: Dr s Name? How long ago? What were the results: o Favorable o Unfavorable à please explain: PLEASE MARK the areas on the Diagram with the following letters to describe your symptoms: R = Radiating B = Burning D = Dull A = Aching N = Numbness S = Sharp/Stabbing T = Tingling What relieves your symptoms? What makes your symptoms feel worse? LIST RESTRICTED ACTIVITY: CURRENT ACTIVITY LEVEL USUAL ACTIVITY LEVEL : : : : Is your problem the result of ANY type of accident? o Yes, o No Explain:
4 Identify any other injury(s) to your spine, minor or major, that the doctor should know about: PAST HISTORY Please identify any and all types of jobs you have had in the past that have imposed any physical stress on you or your body: If you have ever been diagnosed with any of the following conditions indicate with a P for in the Past, C for Currently have or N for Never have had Broken Bone Dislocations Tumors Rheumatoid Arthritis Fracture Disability Cancer Stroke Heart Attack Osteo Arthritis Diabetes Cerebral Vascular Issue Other serious conditions: PLEASE identify ALL PAST and CURRENT conditions you have: Headache Neck Pain Jaw Pain/TMJ Shoulder Pain Upper Back Pain Mid Back Pain Low Back Pain Hip Pain Foot or Knee Problems Elbow or Wrist Problems Back Curvature Scoliosis Skin Problems Numb/Tingling in arms, hands, fingers Numb/Tingling in legs, feet, toes Convulsions/Epilepsy Tremors Chest Pain Pain w/cough/sneeze Pregnant (Now) Frequent Colds/Flu Sinus/Drainage Problem Swollen/Painful Joints Dizziness Loss of Balance Fainting Double Vision Blurred Vision Ringing in Ears Hearing Loss Depression Irritable Mood Changes ADD/ADHD Allergies Prostate Problems Trouble Sleeping Impotence/Sexual Dysfunction Digestive Problems Colon Trouble Diarrhea/Constipation Menopausal Problems PMS Bed Wetting Learning Disability Eating Disorder Ulcers Heartburn Heart Problem High Blood Pressure Low Blood Pressure Asthma Difficulty Breathing Lung Problems Kidney Trouble Gall Bladder Trouble Liver Trouble Hepatitis (A,B,C) Other PLEASE List past surgical operations and the date they occurred: PLEASE List ALL over the counter and prescription medications you are currently taking: When was your last automobile accident? Have you ever been knocked unconscious? When? SOCIAL HISTORY 1. Smoking: cigars pipe cigarettes How often? Daily Weekends Occasionally Never 2. Alcoholic Beverage: consumption occurs Daily Weekends Occasionally Never 3. Recreational Drug use: Daily Weekends Occasionally Never 4. Hobbies -Recreational Activities- Exercise Regime: How often do you exercise? I hereby authorize and request payment for services to be made directly to Cadence Chiropractic for all benefits which may be payable under a healthcare plan or from any other collateral sources. I authorize utilization of this application or copies thereof for the purpose of processing claims and effecting payments, and further acknowledge that this assignment of benefits does not in any way relieve me of payment liability and that I will remain financially responsible to Cadence Chiropractic for any and all services I receive at this office. Patient or Authorized Person s Signature Doctor s Signature Completed Form Reviewed
5 QUADRUPLE VISUAL ANALOGUE SCALE Patient Name Please read carefully: Instructions: Please circle the number that best describes the question being asked. Note: If you have more than one complaint, please answer each question for each individual complaint and indicate the score for each complaint. Please indicate your pain level right now, average pain, and pain at its best and worst. Example: Headache Neck Low Back 1 What is your pain RIGHT NOW? 2 What is your TYPICAL or AVERAGE pain? 3 What is your pain level AT ITS BEST (How close to 0 does your pain get at its best)? 4 What is your pain level AT ITS WORST (How close to 10 does your pain get at its worst)? OTHER COMMENTS: Examiner Reprinted from Spine, 18, Von Korff M, Deyo RA, Cherkin D, Barlow SF, Back pain in primary care: Outcomes at 1 year, , 1993, with permission from Elsevier Science.
6 HEALTH HISTORY OF FAMILY MEMBERS The reason for this form is to assist the doctor by providing past health history information for his review. Condition Self Father Mother Spouse Brothers Sisters Children Arthritis Asthma Back Trouble Cancer Constipation Diabetes Disc Problems Drinker Drug Addiction Emphysema Epilepsy Headaches Heart Trouble High Blood Pressure Kidney Trouble Migraine Nervousness Neuritis Neuralgia Pinched Nerve Sinus Trouble Smoker Sports Activities Stomach Trouble Deceased Do you use orthotics? Copyright
7 INFORMED CONSENT FOR CHIROPRACTIC CARE A patient, in coming to the chiropractic doctor, gives the doctor permission and authority to care for the patient in accordance with the chiropractic tests, diagnosis, and analysis. The chiropractic adjustment or other clinical procedures are usually beneficial and seldom cause any problems. In rare cases, underlying physical defects, deformities or pathologies may render the patient susceptible to injury. The doctor, of course, will not give any treatment or care if he/she is aware that such care may be contra-indicated. Again, it is the responsibility of the patient to make it known, or to learn through healthcare procedures what he/she is suffering from: latent pathological defects, illnesses or deformities which would otherwise not come to the attention of the chiropractic physician. The chiropractic doctor provides a specialized, non-duplicating health care service. Your doctor of chiropractic is licensed in a special practice and is available to work with other types of providers in your health care regimen. I understand that if I am accepted as a patient by a physician at Cadence Chiropractic, I am authorizing them to proceed with any treatment that they deem necessary. Furthermore, any risk involved, regarding chiropractic treatment, will be explained to me upon my request. NOTICE OF PRIVACY PRACTICE ACKNOWLEDGEMENT I understand that I have certain rights of privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to: 1. Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly or indirectly. 2. Obtain payment from third-party payers. 3. Conduct normal healthcare operations, such as quality assessments and physicians certifications. I acknowledge that a more comprehensive version of this Notice Of Privacy Practice is available to me. At this time, I do not have any questions regarding my rights or any of the information I have received. I further understand that this office reserves the right to amend this Notice of Privacy Practice at a time in the future and will make the new provisions effective for all information that it maintains past and present. MEDICAL INFORMATION RELEASE FORM (HIPAA Release Form) Release of Information: [ ] I authorize the release of information including the diagnosis, records; examination rendered to me and claims information. This Release will remain in effect until terminated by me in writing. This information may be released to: [ ] Spouse [ ] Child(ren) [ ] Other [ ] Information is not to be released to anyone. Messages: Please call [ ] my home [ ] my work [ ] my mobile number: If unable to reach me: [ ] you may leave a detailed message [ ] please leave a message asking me to return your call The best time to reach me is (day) between (time)
8 X-RAY AUTHORIZATION As your healthcare provider, we are legally responsible for your chiropractic records; we must maintain a record of your x-rays in our files. At your request, we will provide you with a copy of your x-ray in our files. The fee for copying your X-Rays and Video Fluoroscopy study on a disc is $ This fee must be paid in advance. Digital X-Rays on CD will be available within 72 hours of prepayment and on regular practice hour days. PLEASE NOTE: X-Rays are utilized in this office to help locate and analyze vertebral subluxations. These X-Rays are not used to investigate for medical pathology. The doctors of Cadence Chiropractic do not diagnose or treat medical conditions; however, if any abnormalities are found, we will bring it to your attention so that you may seek proper medical advise. By signing below you are agreeing to the above terms and conditions. Patient Name (Print) Your Age FEMALE PATIENTS ONLY: To the best of my knowledge, I believe I am not pregnant at the time X-Rays are taken at Cadence Chiropractic.
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Whom may we thank for referring you to this office? APPLICATION FOR CARE AT CORE CHIROPRACTIC Today s Date: HRN: PATIENT DEMOGRAPHICS Name: Birth Date: - - Age: Male Female Address: City: State: Zip: E-mail
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SPARROW FAMILY CHIROPRACTIC
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APPLICATION FOR CARE AT LAUNCH CHIROPRACTIC
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Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No
![Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No](/thumbs/89/99616722.jpg "Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No")
Patient Information Welcome Who is responsible for this account? SSN Relationship to Patient Patient Name Insurance Co. Name: Preferred First Name Group #: ID #: Sex [ ] M [ ] F Age: Birthdate SS# Birthdate
Ages 6 to E. Lohman Ave Ste 22 Las Cruces, NM (575) Today's Date: Date of Birth: Phone Number with Area Code:
3961 E. Lohman Ave Ste 22 Las Cruces, NM 88011 (575) 652-3358 Ages 6 to 18 Today's Date: Name: Date of Birth: Sex: Male Female Mailing Address: Parent/Guardian Names & Phone Numbers: Phone Number with
CHIROPRACTIC EXPERIENCE ABOUT YOU REASON FOR THIS VISIT HEALTH HABITS MEDICATIONS YOU TAKE SUPPLEMENTS YOU TAKE
ABOUT YOU CHIROPRACTIC EXPERIENCE NAME: ADDRESS: CITY: HOME PHONE: EMAIL ADDRESS: STATE/ZIP CODE: CELL PHONE: WHO REFERRED YOU TO OUR OFFICE? HAVE YOU SEEN OR HEARD OF OUR OFFICE BECAUSE OF ( ALL THAT
Matthews Family Chiropractic
Dr. John J. Hanna, Director Matthews Family Chiropractic Windsor Square 9808 Northeast Parkway Matthews, NC 28105 (704) 845-0699 CASE HISTORY PLEASE PRINT Name: Home Phone: Address: City: Zip: Page 1 Age:
Please fill out the following form in as much detail as possible. Please Print. Name. Address. City State Zip. Home Phone Office Phone.
CASE NO. Please fill out the following form in as much detail as possible. Please Print Date Name Address City State Zip Home Phone Office Phone E-mail Address Age Date of Birth Occupation Sex (M) (F)
Chiropractic Case History/Patient Information
1 Chiropractic Case History/Patient Information Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Cell Phone: Age: Birth Date: Race: Marital Status: [M] [S ][W] [D] Occupation:
Welcome to Compass Chiropractic!
Welcome to Compass Chiropractic! Name Age Birth Date / / Home Phone: Cell Phone: Preferred Number: Cell / Home Address: City: State: Zip: Occupation: Email Marital Status: M W D S P Spouse s Name: Number
Stacey Dent, D.C., B.C.A.O Three Notch Rd. Unit 104 Hollywood, MD P: F: HarborBayChiropractic.
Stacey Dent, D.C., B.C.A.O. 23620 Three Notch Rd. Unit 104 Hollywood, MD 20636 P: 301-373-3731 F: 301-373-3970 HarborBayChiropractic.com Welcome to Harbor Bay Clinic of Chiropractic! (For any question
Personal Injury Questionnaire. Name: Address: City: State: Zip: Cell Phone: Home phone: Work Phone: Social Security Number:
Personal Injury Questionnaire Name: Address: City: State: Zip: Cell Phone: Home phone: Work Phone: Social Security Number: Email: Date of birth Sex: Male Female Marital States S M D W Date of Accident:
Physical Evidence Chiropractic 7035 Beracasa Way, Suite 103 Boca Raton Florida, Phone# (561) Fax# (561)
7035 Beracasa Way, Suite 103 Boca Raton Florida, 33433 Phone# (561)674-1217 Fax# (561)361-4999 Date File # PERSONAL HISTORY Last Name First Name middle Address City State Zip Date of Birth Age Social Security
Name First Middle Initial Last Today s Date. Address Street City State Zip. Primary Phone # Cell # . Your Occupation Employer
Name First Middle Initial Last Today s Date Address Street City State Zip Date of Birth Age Social Security # Sex: Male Female mm/dd/year Primary Phone # Cell # Email Emergency Contact Name Number Marital
Hill Family Chiropractic Patient Application
Hill Family Chiropractic Patient Application WELCOME TO OUR OFFICE. WE THANK YOU FOR YOUR TRUST! (Please print using black or blue ink. If there is something that does not apply to you please put N/A on
BalanceChiropractic 7165 E University Dr. Suite 102 Mesa, AZ
BalanceChiropractic 7165 E University Dr. Suite 102 Mesa, AZ 85207 480.830.0175 Chiropractic Intake Form Name Date Address City State Date of Birth Age Phone Email Address Employer Emergency Contact Phone
Brisbin Family Chiropractic
Information reviewed with patient: Dr. Initials Today s Date Brisbin Family Chiropractic Name: Sex: Male Female Address: City: Postal Code: Home Ph# Work# Ext# Cell# Preferred number (circle one) Home
Date: Can we leave messages on voice mail at home/work/cell? Yes No. Sex: Male Female SS#: If yes, what type? Auto Work Other.
1 Patient Information : Name: Last First MI Email address: Mailing Address: Phone # (H) (W) (Other) Can we call you at work? Yes No of Birth: Can we leave messages on voice mail at home/work/cell? Yes
PERSONAL INFORMATION. Date of Birth Age (Last) (First) (M.I.) Address City/State Zip. Phone # Home Work Cell
*If the reason for your visit is due to a worker s compensation injury or an automobile accident, please inform the front desk immediately. PERSONAL INFORMATION of Birth Age (Last) (First) (M.I.) Address
Welcome to our Family Chiropractic Office
Welcome to our Family Chiropractic Office Thank you for choosing our office for chiropractic care. We are committed to providing your family with the highest quality of corrective and wellness chiropractic
ABOUT YOU CHIROPRACTIC EXPERIENCE REASON FOR THIS VISIT ABOUT YOUR SPOUSE HEALTH HABITS
NAME: ABOUT YOU WHO REFERRED YOU TO OUR OFFICE? CHIROPRACTIC EXPERIENCE ADDRESS: CITY: HOME PHONE: STATE/ZIP CODE: CELL PHONE: How did you hear about our office? NEWSPAPER SIGN YELLOW PAGES COMMUNITY EVENT
Notto Chiropractic Health Center Patient Information
Notto Chiropractic Health Center Patient Information Acct #: Name: Preferred Name: Address: City: State: Zip: Home Phone: ( ) - _. Work Phone: ( ) -. Who Referred You? In Case of Emergency: Phone Number:
Patient Intake Form. I prefer to receive calls at (circle) Home/Work/Cell I am (circle) Under Age18/Single/Married/Divorced/Widowed/Separated
Patient Information Full Name: First MI Last Patient Intake Form Date: Address: City: State: Zip: Age: Birth Date: Female: Male: Social Security Number: Email Address: Home Phone: Work Phone: Cell/Other:
PERSONAL INJURY QUESTIONNAIRE
PERSONAL INJURY QUESTIONNAIRE Name Phone ( ) Age Birth Date Sex S.S.N. Employer Address Did you report this to YOUR Car Insurance? Yes No (Circle One) Your Car Insurance Co. is Claim # Claims Adjuster
PATIENT APPLICATION FORM
2105 E. Clairemont Ave., Eau Claire, WI 54701 Phone (715)835-9514 Fax (715)835-2602 PATIENT APPLICATION FORM WELCOME TO OUR CLINIC. We specialize in assisting our patients to achieve their highest level
CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.
New Practice Member Forms
New Practice Member Forms Name Date Age Male Female Address City State Zip Phone: Home Cell Cell Phone Provider E-mail SSN Birthday Date of Occupation Employer s Name Single Married Divorced Widowed Spouse
Patient Profile. Full Name: Address: Work Phone: Date of Birth: Social Security #: (Circle One) Full Time / Part Time. Emergency Contact: Number:
Patient Profile Full Name: Address: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security #: Email Address: Employer: (Circle One) Full Time / Part Time Emergency Contact:
History of Present Condition
Name: Date: Address: City: Province: Postal Code: Home Phone: Cell Phone: Work Phone: Email: Marital Status: Name Of Family Physician (MD): Age: Occupation: Employer: Extended Health Care Company: Policy
Date of Birth: Sex: O Male O Female Marital Status? O M O W O D O S. Chiropractic Care
Basic Information Full Name: Address: City: State: Zip: Cell: Home: Work: Date of Birth: Sex: O Male O Female Marital Status? O M O W O D O S Email: Occupation: Emergency Contact: Phone: Children: O No
FRAME CHIROPRACTIC South Price Road, Suite D-110 Tempe, Arizona Phone: Fax:
3330 South Price Road, Suite D-110 Tempe, Arizona 85282 Phone: 480.345.2080 Fax: 480.345.2199 W E L C O M E ABOUT YOU (please print) Today s Date: Patient Name: DOB: Age: SS#: Mailing Address: City: State: