Balanced Wellness New Patient Forms

New Patient Intake Forms

Please answer all questions as thoroughly as possible.

If you need assistance, please call or text 405-584-6119 at any time!
Today's Date

MonthDayYear
Patient Full Name

PrefixFirst NameMiddle NameLast NameSuffix
Preferred Name (if different)
Birth Date

MonthDayYear
Marital Status
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mobile Phone

Area CodePhone Number
Additional Phone (if applicable)

Area CodePhone Number
What type of phone is the additional phone number?
Home, work, spouse, etc.
Email
example@example.com
Employment Status (check all that apply)

Employed Full-TimeEmployed Part-TimePart-Time StudentFull-Time Student
Employer
Occupation
Referral Information
Please let us know how you heard about our office!
Emergency Contact Information
Emergency Contact Full Name
Relationship to Patient
Emergency Contact Phone

Area CodePhone Number
Insurance Information (if applicable)
Insurance Company
Member ID Number
Chief Complaint
The following are questions regarding the current major complaint that bothers you the most. Please answer the questions as thoroughly as possible.
Describe Current Major Complaint*
What issue is bothering you the most?
How long have you suffered from this condition?*
Approx. number of days, weeks, years, etc.
Did the condition begin suddenly or gradually?*
What were you doing at the time of onset?*
Please indicate anything you might think caused your condition or enter NA if not applicable...
Grade intensity/severity of complaint*
Quality of complaint/pain (mark all that apply)*

SharpStabbingBurningAchyDullStiff & Sore
The symptoms are...*

IntermittentConstant
Please describe the frequency and duration of the intermittent episodes.
Episodes per day, week, etc. & how long the episodes last.
Have the symptoms changed since their onset?*

WorseBetterNo Change
Please describe any activities that you like to do that your condition keeps you from doing*
sleeping, playing with children/grandchildren, sports, not applicable, etc....
What makes your condition better?*
rest, ice, medications, not applicable, etc....
What makes your condition worse?*
sitting for long periods, standing for long periods, household chores, working out, not applicable, etc....
Does your condition sometimes spread or move to any other areas?*
Please describe to what other areas your condition radiates.
Please describe any treatments you have received for this condition*
physicians you've seen, treatments you've received, or other things you've tried to improve your condition, not applicable, etc...
Describe any secondary complaints
Please describe any secondary complaints you would like us to address
Medical and Family History
Current Medications & Supplements
Please list medications & supplements or enter NA if not applicable....
Allergies to Medications
Allergies
Please enter any allergies to medications and any other allergies....
Surgeries-Date, Type, & Reason
Please list surgery information or enter NA if not applicable....
Past Injuries, Traumas, & Hospitalizations
Please list relevant major health problems of immediate relatives
Death in Immediate Family
Cause and at what age?
Level of Education Completed
Alcohol Consumption
Tobacco Use
Primary Care Physician's Name
In the area below, please indicate which of the listed conditions below that you or any members of your immediate family are experiencing or have experienced.

Review of Systems

	Myself	Mother	Father	Sibling
AIDS
Anemia
Arthritis
Asthma
Back Pain
Bladder Trouble
Bone Fracture
Bowel Control Loss
Cancer
Concussion
Convulsions
Diabetes
Dislocated Joints
Dizziness
Earache
Epilepsy
Fatigue
Headaches
Heart Trouble
High Blood Pressure
HIV
Indigestion
Kidney Disorders
Menstrual Cramps
Multiple Sclerosis
Neck Pain
Nervousness
Night Sweats
Numbness
Poor Circulation
Reproductive Trouble
Serious Injury
Sinus Trouble
Spinal Curvature
Stroke
Thyroid Problem
Weakness
Weight Gain/Loss

Are you pregnant? (women only)
What is the due date?

MonthDayYear
Date
When was your last menstrual Period?

MonthDayYear
Date
Pregnancies with Outcomes & Dates - If applicable
Comments
If applicable, enter any other information that you think the physicians or staff should know that has not been covered by this form.

Appointment Reminders Preferences:

This office utilizes text messages sent to your mobile phone number that we have on file. We use these to communicate important information such as appointment reminders, office closings due to weather, etc. We will not transmit any protected health information (PHI) via text. Please let us know if you would like to opt-out of communicating with our office via text message at any time!
HIPAA Notice:

Please read the following information and sign below.

I understand and agree to allow this chiropractic office to use their Patient Health Information for the purpose of treatment, payment, healthcare operation, and coordination of care. 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 a more detailed account of your policy and procedures concerning the privacy of your Patient Health Information, we encourage you to read the HIPAA Notice that is available for 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 Signature: (parent if minor)*

Clear
Today's Date:

MonthDayYear
Date
Informed Consent for Treatment:

Please read the following information and sign below.

I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physiotherapy and diagnostic x-rays, on me (or of said minor) by Balanced Wellness Chiropractic Physicians and/or its employees. I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment, including but not limited to fractures, disc injuries, stroke, dislocations, and sprains. In the practice of acupuncture there are some risks to treatment, including but not limited to minor bleeding or bruising, minor pain or soreness, nausea, fainting, infection, and stuck or bent needles. Acupuncture points may have effects on pregnancy. Patients must inform the practitioner of any possibility of pregnancy at any point during the treatment process. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely upon the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known to him/her, is in my best interest. I understand that results are not guaranteed. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.
Patient Signature: (parent if minor)*

Clear
Today's Date:

MonthDayYear
Date

Financial Policy:

Thank you for choosing us as your healthcare provider. The following is a description of our financial policy:
- Payment for services is due at the time services are rendered.
  - We accept cash, checks, Visa, MasterCard, Discover, and American Express.
  - We will be happy to assist you with applying for financing þÿshould you so desire. We do not handle any financing in-house but we do have financing available through Care Credit.
  - We reserve the right to collect before services are rendered.
- All charges are your responsibility whether the insurance company pays or not.
  - Not all services are a covered benefit. Benefits may vary on different insurance plans. It is your responsibility to verify your insurance coverage.
  - Fees for non-covered services, deductibles, and co-payments are due at the time of treatment.
  - If your insurance company does not pay your claim within a reasonable time frame, or if coverage for a particular service and or supply is denied, we may require you to follow up with your insurance and/or pay the balance due.
- Unless you are insured by Medicare or an insurance group in which our doctors are participating members, or double insured (for the procedure being performed), it is our policy to collect 100% payment at the time the services are rendered.
- If you are a member of an HMO responsible for contacting your PCP for a referral number prior to your visit if one is required by your agreement with your insurance company.
- We understand that temporary financial problems may affect the timely payment of your balance. We ask that you speak with an Account Manager if you encounter such problems, so that we may assist you in the management of your account. You may reach an Account Manager at (405) 509-7017.
Again, thank you for selecting us as your health care provider. We appreciate your trust in us and we appreciate the opportunity to serve you. Again, thank you for selecting us as your health care provider. We appreciate your trust in us and we appreciate the opportunity to serve you!
Patient or Guarantor's Signature: *

Clear
Today's Date:

MonthDayYear
Date

Emergency Contact Information

Insurance Information (if applicable)

Chief Complaint

Medical and Family History