Dr. Chris Price, D.C.
Dr. R. Matt George, D.C.
Christina Coley, APN
Linda Poole, APN
Kathryn Smith, APN
PATIENT INTAKE FORM
Name: ______________________________________________________________________
(First)
(Last)
Address: _____________________________________________________________________
City/State: _______________________________Zip:___________________□ Male □ Female
Social Security #:________________________________ DOB: _____/____/______
Email Address: _______________________________________________________
Cell Phone #__________________________ Home Phone #_________________________
How would you prefer us to contact you? □ Home Phone □ Cell Phone □ Text Message □ Email
Emergency Contact: ____________ How were you referred to our office? _________________
Have you recently been involved in an accident? □ Yes □ No When and what type of accident?
_____________________________________________________________________________
Has the Accident been reported? □ Yes □ No
If yes, to whom? □ Employer □ Auto Carrier □ Attorney
*Who is your primary care physician? ____________________________□ I don’t have one
Location: ______________________________ Phone: _______________________
Present Complaints:
Only circle those that apply to you. 0-10 scale, 0 being no pain, 10 being the most severe pain.
Please indicate both the frequency and type of pain for each section, if necessary
Headaches:
0 1 2
3
Neck Pain:
4
5
6
7 8
9 10
0 1
2 3 4 5 6
7 8 9 10
Frequency Of Pain: □ Constant □ Comes/Goes
□Occasional □ Frequent
Frequency Of Pain: □ Constant □ Comes/Goes
□Occasional □ Frequent
Type of Pain: □ Pins & Needles □ Stiffness
□Pulling □ Sharp □ Dull □ Ache □ Burning
□ Shooting □ Stabbing □ Stinging □ Throbbing
Type of Pain: □ Pins & Needles □ Stiffness
□Pulling □ Sharp □ Dull □ Ache □ Burning
□ Shooting □ Stabbing □ Stinging □ Throbbing
Patient Initials_______________ Date ________________
1602 W Ave A
Temple, TX 76504
Dr. Chris Price, D.C.
Dr. R. Matt George, D.C.
Christina Coley, APN
Linda Poole, APN
Kathryn Smith, APN
Mid Back: (□ Right □ Left):
Shoulders (□ Right □ Left):
0 1
0 1
2
3
4 5 6
7 8 9 10
2
3 4
5
6
7 8
9 10
Frequency Of Pain: □ Constant □ Comes/Goes
□Occasional □ Frequent
Frequency Of Pain: □ Constant □ Comes/Goes
□Occasional □ Frequent
Type of Pain: □ Pins & Needles □ Stiffness
□Pulling □ Sharp □ Dull □ Ache □ Burning
□ Shooting □ Stabbing □ Stinging □ Throbbing
Type of Pain: □ Pins & Needles □ Stiffness
□Pulling □ Sharp □ Dull □ Ache □ Burning
□ Shooting □ Stabbing □ Stinging □ Throbbing
Lower Back: (□ Right □ Left):
Arms and Hands (□ Right □ Left):
0 1 2 3
0 1
4
5 6 7 8 9 10
2 3
4
5
6 7
8
9 10
Frequency Of Pain: □ Constant □ Comes/Goes
□Occasional □ Frequent
Frequency Of Pain: □ Constant □ Comes/Goes
□Occasional □ Frequent
Type of Pain: □ Pins & Needles □ Stiffness
□Pulling □ Sharp □ Dull □ Ache □ Burning
□ Shooting □ Stabbing □ Stinging □ Throbbing
Type of Pain: □ Pins & Needles □ Stiffness
□Pulling □ Sharp □ Dull □ Ache □ Burning
□ Shooting □ Stabbing □ Stinging □ Throbbing
Hips (□ Right □ Left):
Other_____________ Pain Level: _________
0 1 2 3 4 5 6 7
8 9 10
Frequency Of Pain: □ Constant □ Comes/Goes
□Occasional □ Frequent
Type of Pain: □ Pins & Needles □ Stiffness
□Pulling □ Sharp □ Dull □ Ache □ Burning
□ Shooting □ Stabbing □ Stinging □ Throbbing
Legs and Feet (□ Right □ Left):
0 1 2 3 4 5 6
7 8 9 10
Frequency Of Pain: □ Constant □ Comes/Goes
□Occasional □ Frequent
Type of Pain: □ Pins & Needles □ Stiffness
□Pulling □ Sharp □ Dull □ Ache □ Burning
□ Shooting □ Stabbing □ Stinging □ Throbbing
What aggravates your condition?
□ Sitting □ Standing □ Bending □ Light
Lifting □ Lying Down □ Walking □ Cold
□Dampness
□Other______________
Frequency Of Pain: □ Constant □ Comes/Goes
□Occasional □ Frequent
What relieves your condition?
□ Bed Rest
□ Ice □ Heat □ Massage □ Medication
Type of Pain: □ Pins & Needles □ Stiffness
□Pulling □ Sharp □ Dull □ Ache □ Burning
□ Shooting □ Stabbing □ Stinging □ Throbbing
□ Other______________
Patient Initials_______________ Date ________________
1602 W Ave A
Temple, TX 76504
Dr. Chris Price, D.C.
Dr. R. Matt George, D.C.
Christina Coley, APN
Linda Poole, APN
Kathryn Smith, APN
Which areas would you like to be treated for today?
_____________________________________________________________________________________
Do these symptoms interfere with your normal living and work? □ Yes □ No How does it interfere?
______________________________________________________________________________________
Were you previously treated for this complaint?
□ Yes
□ No
If yes, name and type of physician? __________________________________________________________
Were X-rays or other diagnostic radiology performed for this condition?
□ Yes
□ No
If yes, please specify ______________________________________________________________________
What type of treatment was prescribed or performed?
________________________________________________________________________________________
Do you have a pacemaker? □ Yes □ No
* Are you pregnant? __________ How many weeks? ____________
Are you currently being treated for or recently diagnosed with cancer? □ Yes Type: ________□ No
Are you being treated for any other medical conditions? □No □Yes If Yes, which:
__________________________________________________________________________________
Medications you now take:
___________________________________________________________________________________
___________________________________________________________________________________
Please List all medication allergies:
_________________________________________________________________________________________________
_______________________________________________________________________
In most instances, an integrated treatment approach speeds recovery from injury. Should the doctor
feel it would be in your best interest, are you willing to be treated by the following care providers within
our office?
Please answer each section.
Nurse Practitioner/Medical Doctor
□ Yes
□ No
Chiropractor
□ Yes
□ No
Massage Therapist
□ Yes
□ No
Patient Initials_______________ Date ________________
1602 W Ave A
Temple, TX 76504
Dr. Chris Price, D.C.
Dr. R. Matt George, D.C.
Christina Coley, APN
Linda Poole, APN
Kathryn Smith, APN
On the next two pages, please only check the
conditions that apply to you, either you currently
have them (now), or have had them in the past.
General
Now Past
o □
Unusual weight gain or loss
o □
Sleep problems
o □
Loss of appetite
o □
Fatigue
o □
Cancer
o □
Alcoholism
o □
Chemical Dependency
o □
AIDs or HIV positive
o □
Measles
o □
Mumps
o □
Rubella (Garmin Measles)
o □
Chicken Pox
o □
Whooping Cough (pertussis)
o □
Tuberculosis (TB)
o □
Lived with someone who had TB
o □
Rheumatic Fever
o □
Polio
o □
Mononucleosis
Muscle/Joint/Bone
Pain, weakness, numbness, or coldness in:
o □
Arms
o □
Back
o □
Feet
o □
Hands
o □
Hips
o □
Legs
o □
Neck
o □
Shoulders
o □
Arthritis, Swollen or Painful Joints
o □
Broken bones
o □
Walking Problems
o □
Scoliosis (Spinal Curvature)
o □
Difficulty chewing/clicking jaw
o □
General Stiffness
o □
Fibromyalgia
o □
Osteoporosis or osteopenia
o □
Muscle Spasms
o □
Muscle Disease
o □
Other:__________________
Patient Initials_______________ Date ________________
Nervous System
Now Past
o □
Nervousness/anxiety
Abdomen, Gastrointestinal
o □
Change of appetite
o □
Bloating/gas
o □
Indigestion/heartburn
o □
Bowel changes
o □
Blood in stools or black tarry stools
o □
Chronic Nausea/vomiting or vomiting
Blood
o □
Chronic constipation or diarrhea
o □
Stomach pain
o □
Hiatal hernia
o □
Peptic ulcer disease
o □
Colitis or inflammatory or bowel
Disease (IBD)
o □
Irritable Bowel Disorder
o □
Hemorrhoids
o □
Hepatitis, jaundice (yellow color)
o □
Appendicitis
o □
Anorexia or bulimia
o □
Hernia
o □
Other:________________
Genitourinary/Renal
o □
Kidney disease
o □
Kidney stones
o □
Excessive urine or frequent urination
o □
Painful urine
o □
Blood in urine
o □
Loss of bladder control
o □
Discolored urine
o □
Other:________________
Skin
o □
Eczema or rash
o □
Psoriasis
o □
Acne
o □
Scars/body marks
o □
Hives
o □
Change in moles or sores that won't
Heal
o □
Skin ulcers
o □
Other:________________
1602 W Ave A
Temple, TX 76504
Dr. Chris Price, D.C.
Dr. R. Matt George, D.C.
Christina Coley, APN
Linda Poole, APN
Kathryn Smith, APN
Now Past
Endocrine/Metabolic
Now Past
Thyroid: enlarged, too high too low
Diabetes
Voice Change
Skin or Hair Change
Temperature Intolerance
Depression
□
Headaches including migraines
□
Seizures (epilepsy), convulsions, fits
□
Dizziness
□
Fainting
□
Forgetfulness, confusion
□
Paralysis
□
Mental disorder or psychiatric care
□
Multiple Sclerosis
□
Stroke
□
Meningitis/encephalitis
□
Head injury, memory loss, amnesia,
Unconsciousness, concussion, other
o □
Other:___________________
Cardiovascular
o □
High blood pressure
o □
High Cholesterol
o □
Chest Pains
o □
Shortness of breath with activity
o □
Shortness of breath at night in bed
o □
Swelling of feet/ankles/lower legs
o □
Heart attack (myocardial infraction)
o □
Angina
o □
Varicose veins
o □
Heart valve problem, murmur
o □
Irregular heartbeat, palpitations
o □
Pacemaker
o □
Blood clots/phlebitis
o □
Poor circulation
o □
Other heart or vascular disease:
Respiratory
o □
Asthma, wheezing or use of inhaler
o □
Bronchitis or pneumonia
o □
Emphysema
o □
Pleurisy
o □
Congestion
o □
Coughing up blood
o □
Chronic Cough
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
□
□
□
□
□
□
Patient Initials_______________ Date ________________
o □
Obstructive sleep apnea (OSA)
o □
Other:___________________
Blood and Auto Immune Disease
o □
Anemia (low red blood cells,
Low iron)
o □
On blood thinners (anticoagulants)
o □
Easy bruising or bleeding
o □
Other blood cell problems
o □
Systemic Lupus
o □
Rheumatoid Arthritis
o □
Other Immune Disease
o □
Gout
o □
Other:___________________
Head, Ears, Eyes, Nose Throat
o □
Severe tooth or gum trouble,
Bleeding gums
o □
Vision problems e.g. blurred vision,
Double vision, halos, flashes
o □
Cataracts
o □
Glaucoma
o □
Hearing difficulty or hearing aids
o □
Ear pain or discharge
o □
Ringing in ears
o □
Balance problems
o □
Nasal or sinus problems
o □
Hoarseness
o □
Nose bleeds
o □
Other:__________________
Male Problems
o □
Breast lump
o □
Prostate problems
o □
Urinary discomfort or discharge
o □
Sores or lumps in genitals
o □
Other:__________________
Female Problems
o □
Breast lump or nipple discharge
o □
Menstrual problems
o □
Unusual vaginal discharge
o □
Abnormal pap smear
o □
Cysts/surgeries
o □
Other:__________________
MD Patients Only:
Date of last menstrual period? _____________
Date of last Pap smear? ___________________
Number of children? _______________
1602 W Ave A
Temple, TX 76504
Dr. Chris Price, D.C.
Dr. R. Matt George, D.C.
Christina Coley, APN
Linda Poole, APN
Kathryn Smith, APN
SOCIAL HISTORY
□ Caffeine (coffee, energy, tea, etc.) Amount/day? __________
□ Alcohol amount/day? ___________
□ Nicotine (chewing tobacco, cigarettes, snuff, etc.) Amount/day? ______________________
□ Drugs (illegal or not prescribed prescription drugs) amount/type? ______________________
PAST HEALTH HISTORY
Please check or describe
Major Surgery / Operations: □ Back Surgery □ Tonsillectomy □ Hysterectomy □ Hernia
□ Gall Bladder □ Appendectomy □ Other: ___________________________________________
Hospitalizations (other than above):
____________________________________________________________________________
Other serious injuries/illnesses not listed:
_____________________________________________________________________________
_____________________________________________________________________________
Please list any STD’s:___________________________________________________________________
Have you ever had a blood transfusion? □ Yes □ No
FAMILY HEALTH HISTORY
Does your family have any history of the following? (1st degree relatives ONLY)
□ Diabetes
□ Cancer
□ Back Pain/Arthritis
□ High Blood Pressure □ Kidney Disease
□Asthma/Hay Fever
□ Heart Disease
□ Chemical Dependency
□ Other: _____________
Authorization to Treat:
If patient is under 18, Parent/Guardian must sign
I hereby authorize Dr. Chris Price, Christina Coley, APN, Dr. Matt George and/or their staff to examine
and/or treat my condition as he/she deems appropriate. I also certify that the above information is correct
to the best of my knowledge. I will not hold my doctor or any member of his/her staff responsible for any
errors or omissions that I may have made in the completion of this form.
Patient’s Signature: ___________________________________ Date____________________________
Parent/Guardian Signature: _____________________________ Date: ___________________________
Patient Initials_______________ Date ________________
1602 W Ave A
Temple, TX 76504
Dr. Chris Price, D.C.
Dr. R. Matt George, D.C.
Christina Coley, APN
Linda Poole, APN
Kathryn Smith, APN
HIPAA Notice of Privacy Practices
____________________________________________________ (Name)
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESSTO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to
carry out treatment payment or health care operations (TPO) and for other purposes that are permitted or required by
law. It also describes your rights to access and control your protected health information. "Protected health
information" is information about you, including demographic information, that my identify you and that relates to your
past, present or future physical or mental health or condition and related health care services.
Uses and Disclosures of Protect Health Information
Your protected health information may be used and disclosed by your physician, our office staff and others outside of
our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay
your health care bills, to support the operation of the physician's practice and any other use required by law.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health
care and any related services. This includes the coordination or management of your health care with a third party.
For example, we would disclose your protected health information as necessary, to a home health agency that
provides care to you. For example, your protected health information may be provided to a physician to whom you
have been referred to ensure that the physician has the necessary information to diagnose or treat you.
Payment: Your protected health information will be used, as needed, to obtain payment for your health care services.
For example, obtaining approval for a hospital stay may require that your relevant protected health information be
disclosed to the health plan to obtain approval for the hospital admission.
Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the
business activities or your physician's practice. These activities include, but are not limited to, quality assessment
activities, employee review activities, training of medical students, licensing, and conducting or arranging for other
business activities. For example, we may disclose your protected health information to medical school students that
see patients at our office. In addition, we may use a sign in sheet at the registration desk where you will be asked to
sign your name and indicate your physician. We may also call you by name in the waiting room when your physician
is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind
you of your appointment.
We may use or disclose your protected health information in the following situations without your authorization. These
situations include: as Required By Law, Public Health issues as required by law, Communicable Diseases: Health
Oversight: Abuse or Neglect: Food and Drug Administration requirements: Legal Proceedings: Law Enforcement:
Coroners, Funeral Directors, and Organ Donation: Research: Criminal Activity: Military Activity and National Security:
Worker’s Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you
an when required by the Secretary of the Department of Health and Human Services to investigate or determine our
compliance with the requirements of Section 164.500.
Patient’s Signature: ___________________________________Date:___________________
Patient Initials_______________ Date ________________
1602 W Ave A
Temple, TX 76504
Dr. Chris Price, D.C.
Dr. R. Matt George, D.C.
Christina Coley, APN
Linda Poole, APN
Kathryn Smith, APN
Patient Information and Consent Form
Medical Informed Consent
Therapeutic exercises and physical therapy medical procedures are considered safe and effective methods of care.
Occasionally, however, complications may arise. Any procedure intended to help may have complications. While the
chances of experiencing complications are minimal, it is the practice of this clinic to inform our patients about them.
These complications may include but are not limited to soreness, inflammation, soft tissue injury or bruising,
dizziness, burns, and temporary worsening of symptoms. More serious complications are extremely rare. It is our
policy to inform you of the procedure being performed and the risks and alternative treatments available. If your
physician does not explain to your satisfaction, please ask for more information.
The purpose of chiropractic is to restore and maintain the integrity of the spinal cord and its nerve roots. A
misalignment of the spinal bones, which interferes with the nervous system, is called SUBLUXATION. Subluxations
come from many causes and prevent various organs, glands, tissues, and muscles from functioning properly.
The goal of chiropractic is to adjust the vertebral subluxations for the purpose of allowing the body to function properly
and to heal itself. Chiropractic does not treat disease or symptoms. The Chiropractor's only goal is to allow the body
to function properly and one such means is the correction of vertebral subluxations.
Please understand that chiropractic is NOT a substitute for medical treatment of any kind. In addition, NO statement
of the chiropractor is intended as medical diagnosis and should not be confused as such. Chiropractic is not intended
to be a treatment of medical conditions or to treat the causes of a medical condition.
When any medical test or procedure is performed, certain risk is always involved. When you intake any drug or
medication, there exists a risk of dangerous side effects as well. Risks are involved when you walk down a flight of
stairs, drive or ride in a car, or play sports.
Chiropractic adjustments are extremely safe. However, chiropractic adjustments still pose a degree of risk in certain
situations.
The most common side effect is post adjustment muscle soreness and is seen in only a small percentage of people. It
is comparative to post exercise muscle soreness, and typically subsides quickly. Should you experience any post
adjustment sensations, please tell the doctor on you next visit.
Although extremely rare, there is a potential risk of stroke from chiropractic manipulation. If you have any concerns or
questions about the safety of chiropractic in certain situations, please tell the doctor. The doctor will be happy to
address any and all concerns you may have. You may rest assured the doctor will do his utmost to care for you in the
safest and most effective manner, just as he would care for his own family.
I, _______________________________ have read and fully understand the information and consent to medical care,
chiropractic care and massage/physical therapy on this basis.
Patient Signature: ___________________________________________Date:___________________________
If Patient is Under 18: Parent/Guardian Signature: ___________________________Date:__________________
Patient Initials_______________ Date ________________
1602 W Ave A
Temple, TX 76504
Dr. Chris Price, D.C.
Dr. R. Matt George, D.C.
Christina Coley, APN
Linda Poole, APN
Kathryn Smith, APN
Please Read The Following Information and Sign Where Indicated
I understand that the massage/bodywork I receive is provided for the basic, purpose of
relaxation and relief of muscular tension. There are certain medical conditions in which receiving
a massage may not be appropriate. In those cases a referral from a physician may be required
prior to services being provided. Massage/bodywork is not a substitute for medical attention
received by a medical specialist. If I experience any pain or discomfort during the session, I will
immediately inform the therapist so that the pressure/strokes may be adjusted. In addition, if I
am uncomfortable for any reason, I may ask that the session be stopped immediately.
Draping will always be used during massage/bodywork sessions. No breast massage shall be
done unless prescribed by a doctor. Any illicit or sexually suggestive remarks or advances made
by me (the client) will result in the immediate termination of the session.
Client Signature: ________________________________ Date: _________________________
Massage Patients Only
On this diagram please circle the areas of the body that you feel
need the most attention in the massage session.
If applicable, please place an “X” over areas you would
like to have avoided.
For Therapist Use ONLY:
Services to be performed today: _____________________________________
_______________________________________________________________
Type of massage techniques used during the massage session:
________________________________________________________
Therapist's Signature: _______________________________Date________________________
Patient Initials_______________ Date ________________
1602 W Ave A
Temple, TX 76504