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.

Patient Information

Name *

First

Last

Email *

Phone *

Gender

Male
Female

Date of Birth

Social Security #:

Height (Feet, Inches)

Weight

Marital Status

Spouse's Name

Number of Children

Address

Address Line 1

Address Line 2

City

State

Zip Code

Complaint Information

If you have more than one complaint, address your primary complaint in your responses to the questions in this section and select Yes to indicate that you have an additional complaint. The form will populate a secondary question section for you to address your additional complaint. You may address up to four complaints.

What is the purpose of your visit?

What is the reason for this visit?

Date of scheduled appointment

When did this condition begin?

How long have you had this condition?

What caused this condition?

Where is the discomfort?

Select only one area of discomfort for your chief complaint. Add additional areas of discomfort as additional complaints by selecting Yes in response to Do you have an additional complaint? at the bottom of this section.

Head

Front of head
Right side of head
Back of head
Left side of head

Neck

Front of neck
Right side of neck
Back of neck
Left side of neck

Back

Trunk

Upper Extremity

Lower Extremity

Does the discomfort radiate/travel?

Yes
No

Describe the quality of the discomfort. Choose all that apply.

Describe the onset of the discomfort. Choose only one.

Describe the intensity of the discomfort. Choose only one.

Rate the severity of your discomfort on a scale of 1-10 where 1 is the least severe and 10 is the most severe.

Least severe <--------------------------------------------------------------------------------------------> Most severe

How often do you feel this discomfort? Choose only one.

How has this complaint changed since the onset?

Improved
Stayed the same
Worsened

What activity is most significantly affected by this discomfort?

What aggravates this condition? Choose all that apply.

What improves this condition? Choose all that apply.

What treatment have you received for this condition up to now?

Were any diagnostic tests performed to assess this condition (including X-rays, MRIs, etc.)?

Yes
No

Have you ever had any previous episodes of this condition?

Yes
No

In what ways does this condition affect your life and your ability to function? Choose all that apply.

Do you have an additional complaint?

Yes
No

Review of Systems

Musculoskeletal

No additional musculoskeletal complaints
Additional musculoskeletal complaints

Please Check Additional musculoskeletal complaints.

Neurological

No additional neurological complaints
Additional neurological complaints

Please check additional neurological complaints

Head, Eyes, Ears, Nose and Throat

No complaints
Head, eyes, ears, nose and throat complaints

Please check additional complaints

Cardiovascular

No cardiovascular complaints
Heart or blood vessel complaints

Please check additional cardiovascular complaints

Respiratory

No respiratory complaints
Breathing or lung complaints

Please check additional Respiratory complaints

Gastrointestinal

No gastrointestinal complaints
Stomach or intestinal complaints

Please check additional Gastrointestinal complaints

Genitourinary

No genitourinary complaints
Genital or bladder or urinary complaints

Please check additional Genitourinary complaints

Endocrine

No endocrine complaints
Hormonal or glandular concerns

Please check additional Endocrine complaints

Dermatological and Bleeding

No skin or bleeding complaints
Skin or bleeding concerns

Please check additional Dermatological and Bleeding complaints

Past, Family and Social History

List your (or the patient's) past surgical history. Choose all that apply and indicate the year in which the surgeries were performed.

Yes, surgical history
No surgical history

If yes, Please check

Describe any past illnesses or conditions the doctor should be aware of and the age at which the illness(es) reportedly occurred. Respond respectively to each illness listed. If personal health history is good, select "No past illnesses (including diabetes, cancer, hypertension and progressive neurological diseases)"

Yes, past illnesses
No past illnesses (including diabetes, cancer, hypertension and progressive neurological diseases)

If yes, Please check (copy)

List any past history of accidents or trauma. Choose all that apply.

Are you presently taking any medication?

Yes
No

Which of the following medications are you presently taking? Choose all that apply.

List your (or the patient's) family health history. Choose all that apply to blood relatives only.

What are your (or are the patient's) current work habits? Choose all that apply.

How would you describe your (or the patient's) personal social habits? Choose all that apply.

How would you describe your (or the patient's) present exercise habits? Choose all that apply.

How would you describe your (or the patient's) diet and nutritional status? Choose all that apply.

Employment Information

Regular Work Status

Employer Name

Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

What is the purpose of your visit?

Wellness
Complaint
Injury
Other

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

Insurance Name:

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

ID/Policy #:

Group #:

Insured's Name:

Insured's Date of Birth:

Secondary Insurance

Insurance Name:

Phone:

Address

Address Line 1

Address Line 2

City

State

Zip Code

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

Personal Health History

Date of Last Physical Exam

Name of Family Physician or Physician Seen

Physician Phone

Physician Address

Address Line 1

Address Line 2

City

State

Zip Code

Please list any health conditions that you have been treated for in the last year:

condition, cause, current/resolved

Have you had previous chiropractic care?

Yes
No

Condition(s) treated

Date of last chiropractic visit:

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

Yes
No

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

Yes
No

List current medications:

name, amounts, frequency, length of use, reason for use

List current vitamins, minerals, supplements, or herbs:

(name, amounts, frequency, length of use, reason for use)

Chiropractic Experience

Who referred you to our office?

Where did you hear about us?…

Have you been adjusted by a chiropractor before?

Yes
No

If yes…

What was the reason for those visits?

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

Yes
No

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.

Checkboxes

I want the Doctor to select the type of care appropriate for my condition.
Relief care: Symptomatic relief of pain or discomfort.
Corrective care: Correcting and relieving the cause of the problem as well as the symptom.
Comprehensive care: Bring whatever is malfunctioning in the body to the highest state of health possible with Chiropractic care.

Auto Accident

Date / Time

Date

Time

Street / Location:

Make & Model

# of persons in your vehicle

Were you the

Were you

Speed of your vehicle

Speed of their vehicle:

Were you wearing a seat belt?

Yes
No

Have you worked since this injury?

Yes
No

Are your work activities restricted?

Yes
No

Were there any witnesses?

Yes
No

Did the vehicle have airbags?

Yes
No

Did the airbags inflate?

Yes
No

Did the police arrive?

Yes
No

Police report filed?

Yes
No

Visited a Hospital or Doctor?

Yes
No

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?

Yes
No

Medication prescribed?

Yes
No

Were you rendered unconscious?

Yes
No

How long?

Traffic violation issued?

Yes
No

To Whom?

Retained an attorney?

Yes
No

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?

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:

Authorization

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. I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors see fit. 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 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 agree with this statement of authorization

Patient Intake Form

Patient Intake Form

Patient Information

Complaint Information

Where is the discomfort?

Review of Systems

Past, Family and Social History

Employment Information

Insurance & Payment for Care

Personal Health History

Chiropractic Experience

Goals for Your Care

Auto Accident

Authorization

Office Hours

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