New Patient INTAKE Form

CARABASI CHIROPRACTIC CENTER

New Patient Health History
Confidential Patient Health Record
Today's Date:*

MonthDayYear
Date
ID No
Legal Name*

First NameLast NameSuffix
Date of Birth:*

MonthDayYear
Date
Age*
Sex:*

MaleFemale
PERSONAL HISTORY
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*
Please enter a valid phone number.
Home Phone Number*
If you do not have a home number, enter your cell phone again.
E-mail Address:*
example@example.com
Social Security #:
This is helpful if you are using insurance
Check One:*

Married/Civil UnionSingleSeparatedDivorcedWidowed
Business Employer:*
Type of Work:*
Business Phone
Please enter a valid phone number.
Name of Spouse/Partner:
Are Covered Under Your Spouse/Partner's Insurance?

YesNo
Partner’s Employer (if insured through Partner):
Partner’s Type of Work:
Partner’s Business Phone:
Do You Have Children?

YesNo
Name and Ages of Children:
Who can we thank for referring you? How did you hear about us?*
Name of Emergency Contact:*
Emergency Contact Phone:*
Who is responsible for your bill, You and:*

Spouse/PartnerHealth InsuranceMedicareAuto Insurance (PIP)Worker's CompSelf Pay/No Insurance
Personal Health Insurance (Name)
Member ID#:
Insured Person’s Name:
Insured’s Date of Birth:

MonthDayYear
Date
CURRENT HEALTH CONDITION
Unwanted Health Condition (Reason for Visit):*
Other Doctors Seen For This Condition:*

YesNo
Who?
Type of Treatment:
Results:
When Did This Condition Begin?:*
Has This Condidtion Occurred Before?*

YesNo
Condition result of an Accident?*

NoYes
If Yes, select accident type:

On The JobAuto AccidentHome InjuryFallOther
Date of Accident:

MonthDayYear
Date
Time of Accident:
If Work Realted, Have You Made A Report of Your Accident To Your Employer:

YesNo
Medications you now take:

Nerve PillsPainKillers/Muscle RelaxersBlood PressureInsulinList Other Medications Below:
Do You Wear a Shoe Lift?*

YesNo
Do You Suffer From any Condition Other Than That Which You Are Now Consulting Us?*

YesNo
Explain:
PAST HEALTH HISTORY
Major Surgery/Operations

AppendectomyTonsillectomyGall BladderHerniaBack SurgeryBroken BonesOther
Major Accidents or Falls:
Hospitalization (Other Than Above):
Previous Chiropractic Care:*

YesNo
Previous Doctor’s Name:
Previous Doctor's Location:
Approximate Date of Last Chiropractic Visit:

MonthDayYear
Date
Reason For Changing:
INTAKE: Check anything that applies to you

CoffeeTeaSodaAlcoholCigarettesWhite Sugar
Below are a list of diseases which may seem unrelated to the purpose of your visit. However, these questions must be answered carefully as these problems can affect your overall course of care:

CHECK ANY OF THE FOLLOWING DISEASES THAT YOU HAVE HAD:*

Rows	*
Pneumonia
Pneumatic Fever
Polio
Tuberculosis
Cancer
Anemia
Mumps
Small Pox
Chicken Pox
Diabetes
Whooping Cough
Heart Disease
Thyroid
Influenza
Pleurisy
Arthritis
Epilepsy
Mental Disorders
Lumbago
Eczema
Measles
None of Above

CHECK ANY OF THE FOLLOWING YOU HAVE HAD IN THE PAST 6 MONTHS:

MUSCULO-SKELETAL CODE:*

Rows	*
Low Back Pain
Pain Between Shoulders
Neck Pain
Arm Pain
Joint Pain/Stiffness
Walking Problems
Difficult Chewing/Clicking Jaw
General Stiffness
None of Above

NERVOUS SYSTEM CODE:*

Rows	*
Nervous
Numbness
Paralysis
Dizziness
Forgetfulness
Confusion/Depression
Convulsions
Cold/Tingling Extremities
Stress
None of Above

GENERAL CODE:*

Rows	*
Fatigue
Allergies
Loss of Sleep
Fever
Headaches
None of Above

GENITO-URINARY CODE:*

Rows	*
Bladder Trouble
Painful/Excessive Urination
Discolored Urine
None of Above

C-V-R CODE:*

Rows	*
Chest Pain
Short Breath
Blood Pressure Problems
Irregular Heartbeat
Heart Problems
Lung Problems/Congestion
Ankle Swelling
Stroke
None of Above

EENT CODE:*

Rows	*
Vision Problems
Dental Problems
Ear Aches
Sore Throat
Hearing Difficulty
Stuffed Nose
None of Above

GASTRO-INTESTINAL CODE:*

Rows	*
Gas/Bloating after Meals
Heartburn
Black Bloody Stool
Colitis
Poor/Escessive Appetite
Excessive Thirst
Frequent Nausea
Vomiting
Diarrhea
Constipation
Hemorrhoids
Liver Problems
Gall Bladder Problems
Abdominal Cramps
None of Above

FAMILY HISTORY - The following members have a same or similar problem as I do:*

Rows	*
Mother
Father
Brother
Sister
Spouse/Partner
Child
Does Not Apply to Me

MALE ONLY:

Prostate/Sexual Dysfunction Other ProblemsOther
FEMALE ONLY:
Date of Last Period: MM/DD/YYYY
Take Birth Control:   Yes   No
Are You Pregnant?
Yes   No   Unsure
FEMALE ONLY:

Menstrual IrregularityMenstrual CrampsVaginal Pain/InfectionBreast Pain/LumpsOther
Relief Care is that necessary to get rid of your symptoms or pain but not the cause of it. This is the same as drying a floor that was getting wet from a leak but not fixing the floor.
Corrective Care differs from relief care in that the goal is to get rid of the symptoms or paid while correcting the cause of the problem. Corrective care varies in length of time but is more lasting.
Most patients that come to our office have one of two objectives in mind concerning their health care. Some patients come for symptomatic relief of pain or discomfort Relief Care Others are interested in having the cause of the problem as well as the symptoms corrected and relieved Corrective Care Your doctor will weigh your needs and desires when recommending your treatment program. Please Check the type of care desired so that we may be guided by your wishes whenever possible.*

Relief CareCorrective CareI want the doctor to select the type of care appropriate for my condition
Patient's Signature*

Clear
I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself.

I understand that Carabasi Chiropractic Center will assist me in making collection from the insurance company and that any amount authorized to be paid directly to Carabasi Chiropractic Center will be credited to my account on receipt.

I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I agree that I am responsible for all bills incurred at this office. I also understand that if I suspend or terminate, any fees for professional services rendered me will be immediately due and payable.

I hereby authorize the doctors of Carabasi Chiropractic Center to treat my condition as they deem appropriate.
Patient's Signature*

Clear
Consent to Treat a MinorParent/GuardianName:
Parent/Guardian Signature Authorizing Care:

Clear
Should be Empty:

CARABASI CHIROPRACTIC CENTER

PERSONAL HISTORY

CURRENT HEALTH CONDITION