New Patient Intake Form
Patient Information
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Name
*
First Name
Last Name
Date of Birth
*
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Month
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Day
Year
Date
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Address
*
Street Address
Street Address Line 2
City
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Postal / Zip Code
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Email
example@example.com
Occupation
*
Company/Position
Insurance Information
Company
Policy/ID Number
Emergency Contact
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Relationship
*
Referral Source
How did you hear about our clinic? If it was from another patient, please list their first and last name.
Current Complaint
Please Fill In All Blanks
Reason for Visit (Be Specific)
*
What is bothering you today, and what caused this issue?
When did this problem begin?
*
-
Month
-
Day
Year
Date
What type of pain are you experiencing?
*
Sharp pain
Numbness
Dull pain
Tingling
Burning
Throbbing
Pins and Needles
None of the Above
On scale of 1-10, how much pain are you feeling right now?
*
1
2
3
4
5
6
7
8
9
10
No Pain
Worst Pain of My Life
1 is No Pain, 10 is Worst Pain of My Life
What activities increase your pain?
*
What activities decrease your pain?
*
Is this problem related to a recent motor vehicle accident?
*
Yes
No
Medical History
Please Fill In All Blanks
Please list any health conditions or diseases:
*
Please write none if nothing applies
Have you ever had a stroke, spinal fracture, spinal dislocation, or spinal surgery?
*
Yes
No
Have you previously been hospitalized? If yes, please indicate when and why:
*
Have you had any surgery in the past? If yes, please indicate the name/location of the surgery and approximate date:
*
Are you currently taking any medications? If yes, please list them below:
Medical Doctor
First Name
Last Name
Authorization and Consent
I confirm that all information given in this form is true, complete, and accurate.
I understand that Moore Chiropractic is a cash practice, and that I am required to pay for services at the time they are rendered. Although Moore Chiropractic will file certain insurance claims as a courtesy, I understand that reimbursement is ultimately between me and my insurance company.
I understand that Moore Chiropractic is soley focused on the detection and reduction of subluxations (segmental dysfunctions), and that I will be referred to an appropriate medical professional if any non-chiropractic findings are encountered during my examination or treatment.
I understand that based on the current standard of care, medical imaging is not indicated for new patients unless certain red flag symptoms are present. If my condition does not show improvement within a reasonable timeline, I may be referred out for medical imaging by my chiropractor.
I acknowledge that no assurance was offered about the outcome of care.
I release Moore Chiropractic of any responsibility in case of accident, illness, or injury.
I acknowledge that I have received, reviewed, and understand the Notice of Privacy Practices which describes the clinic's policies and procedures regarding the use and disclosure of any protected health information received, created, or maintained in the clinc.
Signature
*
Legal Guardian Signature if Patient is Under 18 Years Old
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