ChiroConnexion Intake Form
Referred by
Please let us know who referred you to us
Patient Information
Name
*
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Phone Number
-
Area Code
Phone Number
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Emergency Contact Person
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship
Medical Doctor's Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Hospital Name
Medical Data
Is this visit related to a Motor Vehicle Accident/Collision?
*
Yes
No
Purpose of visit or complaint
*
Date of Collision
-
Month
-
Day
Year
Date
City where collision occured
How many ppl were in the vehicle at the time of the collision?
Do you have an attorney?
Yes, I have representation
No, I need assistance obtaining an attorney
If yes, Attorney Information
Name and Contact Information
When did you start experiencing this problem?
-
Month
-
Day
Year
Date
Select all symptom regions related to your pain
Headaches
Migraines
Neck Pain
Low Back Pain
Upper Back Pain
Arm/Hand Pain
Shoulder
Elbow
Wrist Pain
Jaw Pain
Excessive Fatigue
Hip Pain
Leg or Foot Pain
Knee/Ankle Pain
Dizziness/Vertigo
Joint Swelling
Other
What type of pain are you experiencing?
Numbness
Sharp pain
Tingling
Burning
Dull pain
Stiffness
In scale of 1-10, how much pain are you feeling right now?
1
2
3
4
5
6
7
8
9
10
Worst
Best
1 is Worst, 10 is Best
Are you pregnant, breastfeeding, or nursing? (Female)
Yes
No
Are you wearing any implantable medical devices? If yes, what are these devices?
Are you currently taking any medications? If yes, please list them below:
Were you previously hospitalized for this condition? If yes, please indicate when and why:
Did you undergo any surgery in the past? If yes, please indicate the name or location of the surgery:
Have you experienced any pain in any part of your body? If yes, please indicate what body part. Please be specific.
Have you been to Chiropractor before?
Yes
No
If yes, Chiropractor's Name and year last seen
How did you hear about us?
Google
Facebook
Instagram
Linkedin
Email
Friend Referral
Other
When would you like to Schedule your Virtual Consultation?
*
Authorization and Consent
I confirm that all information given in this form is true, complete, and accurate.
I released this organization for any responsibility in case of accident, illness, or injury.
I acknowledge that no assurance was offered about the outcome.
I acknowledge that I received an Informed Consent document and the health staff explained it to me thoroughly.
HIPAA:
I confirmed that I have read and received the HIPAA Privacy Practices of this chiropractor's office regarding protected health information
Signature of the Patient
*
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