New Patient Intake Form

Name *

First Name Last Name

Date of Birth *

Date

Gender *

Phone Number *

Area Code Phone Number

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

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.

Reason for Visit (Be Specific) *

What is bothering you today, and what caused this issue?

When did this problem begin? *

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

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

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

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 Clear

New Patient Intake Form

Patient Information

Current Complaint

Medical History

Authorization and Consent