New Patient Intake Form
Personal Information
Date:
How did you hear about us?
Name:
Sex:
Age:
Male
Female
State:
Date of Birth:
SSN:
Address:
Zip:
City:
Phone (Home):
Phone (Cell):
Preferred Method of Contact: TEXT CALL E-MAIL For Text Reminders please list your cell carrier
E-mail:
Single Married Widowed Divorced
Spouse Name:
Children: Y N
Age:
Occupation:
Ages:
Employed / Student / Retired / Other
Title:
State:
Employer/School:
Address:
Zip:
City:
Phone:
Job Activities:
Emergency Contact:
Phone:
Relationship:
Medical Information
Please list ALL current medical conditions & Medications you are taking:
Do you suffer from any condition other than what you are in for today: Y
N
If YES please explain:
Have you been treated for any health condition in the last year:
Have you been hospitalized in the last year: Y
Y
N
If YES please explain
N If YES please Explain:
Surgeries you have had:
Previous Chiropractic Care
Name of chiropractor:
Condition treated:
Results of treatment:
Date of last visit:
How often did you get treatment (i.e. 2 times a week for 6 weeks):
Your Injury, Illness, or Condition
What is the primary reason for your visit today?
Rate your pain on a 0-10 scale 0 = No pain 10 = Extremely painful
0
1
2
3
4
5
6
7
8
9
10
What daily activities are difficult to do you because of your pain?
What activities would you like to be able to do again but can’t because of pain?
How important is it to YOU to get your problem corrected? 0 = Not Important 10 = Extremely Important
0
1
2
3
4
5
6
7
8
9
10
Names of other doctors seen for this condition
Type of previous treatment and/or surgery for this condition
Results of previous treatment (circle): Good
Fair
Poor
Other
Health Information
Please MARK next to any conditions that you have NOW or have had in the PAST.
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Notes
Headache
Migraines
Memory Loss
Dizziness/Vertigo
Allergies
Ear Pain/ Infection
Jaw Pain
Neck Pain
Whiplash
Arm Pain
Shoulder Pain
Elbow Pain
Wrist Pain
Hand Pain
Finger pain or locking
Carpal Tunnel Syndrome
Cold/Tingling/Numbness
in Fingers/Toes
Loss of Grip Strength
Upper Back Pain
Pain Between Shoulder
Blades
Pain When Breathing
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Difficulty Breathing
Asthma
Scoliosis
Low Back Pain
Leg Pain
Hip Pain
Knee Pain
Ankle Pain
Foot Pain
Problems Walking
Heel Pain/Plantar Fasciitis
Back of Heel Pain
Tight Muscles
Heart Attack
Heart Disease
High Cholesterol
Stroke
High Blood Pressure
Diabetes
Dislocations
Fractured/Broken Bones
Metal Screws or Implants
Electronic Implants
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Pacemaker
Spinal Taps
Fainting
Cancer
Tumor
Cysts
Numbness
Bulged/Ruptured Disc
Aneurysm
Seizures
Depression
Multiple Sclerosis
Alzheimer’s
Bowel/Bladder Problems
Digestive/Stomach
Problems
Spinal infections
Spinal Surgery
Unexplained Fever
Arthritis
Sleeping Problems
Nutritional/Exercise History
How much SODA or POP do you drink in a week?
Ounces of Water per DAY:
Do you feel that your diet is
Meals per day 1 2 3 4
Great
More
Do you take a multivitamin? Y
Okay
Needs Help
Is your diet
N
Balanced
High Fats/Carbs
Brand/Vitamins
What are your HEALTH goals? (i.e. lose weight, eat better…etc.)
Would you like us to help you with your health goals? Y
Exercise days per week: 0 1 2 3 4 5
N
Time: 30min
45min
60min
More
Type: Aerobic
Weights
Social History
Do you smoke: Y
N
Have you tried to quit:
Do you drink Alcohol: Y
Recreational Drugs: Y
Packs per day:
Y
How long have you been smoking:
N Are interested in quitting:
N
Y
N
If yes how often & how many drinks?
N
Family History
Please MARK next to any condition that someone in your family HAS or has HAD
o
o
o
o
o
o
o
o
Fainting
Scoliosis
Birth Defects
Headaches
Diabetes
Osteoporosis
Heart Attack
High Blood Pressure
o
o
o
o
o
o
o
o
Cancer
Stroke
Tumor
Aneurysm
Seizures
Allergies
Memory Lapse
Dizziness
o
o
o
o
o
o
o
Stomach Problems
Digestive Problems
Heart Disease
Spinal Infections
Arthritis
Alcoholism
Addiction
Treatment Authorization
I hereby authorize this office and its staff and doctors to examine and treat my condition as the doctors deem appropriate
and I give authority for these procedures to be performed. I clearly understand and agree that all services rendered me
are charged directly to me and that I am responsible for payment of services by this office and all outside laboratory or
radiology services performed on my behalf. Should collection of past due amount become necessary, I will become
responsible for all charges, fees and attorney fees. I (we) hereby authorize the doctor to release all information necessary
to secure payment of benefits. I understand that statements made in any video presentation are made by non-doctors. I
authorize the use of this signature on all insurance submissions and I certify my sole purpose of entering this office is for
healthcare.
The patient understands and agrees to allow this chiropractic office to use their Patient Health Information for the purpose
of treatment, payment, healthcare operations, and coordination of care. The patient understands and agrees to allow this
chiropractic office to contact them via electronic means such as through phone, fax, email, etc. We want you to know how
your Patient Health Information is going to be used in this office and your rights concerning those records. If you would like
to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information
we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent. If there
is anyone you do not want to receive your medical records, please inform our office.
Patient’s signature (x)
Date
HIPAA privacy Signature page
PRACTICE'S REQUIREMENTS
1. The Practice:
•
Is required by federal law to maintain the privacy of your PHI and to provide you with this
Privacy Notice detailing the Practice's legal duties and privacy practices with respect to
your PHI.
•
Is required to abide by the terms of this Privacy Notice.
•
Reserves the right to change the terms of this Privacy Notice and to make the new Privacy
Notice provisions effective for your entire PHI that it maintains.
•
Will distribute any revised Privacy Notice to you prior to implementation.
•
Will not retaliate against you for filing a complaint.
Patient Signature:__________________________________ Date: ___________________
Would you like a full copy of your HIPPA privacy agreement?
Y
N