• New Patient Intake

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Birth Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Please check any and all insurance coverage that may be applicable in this case:*

  • AUTHORIZATION AND RELEASE: I authorize payment of insurance benefits directly to the chiropractor or chiropractic office. I authorize the doctor to release all information necessary to communicate with personal physicians and other healthcare providers and payors and to secure the payment of benefits. I understand that I am responsible for all costs of chiropractic care, regardless of insurance coverage. I also understand that if I suspend or terminate my schedule of care as determined by my treating doctor, any fees for professional services will be immediately due and payable.

    The patient understands and agrees to allow this chiropractic office to use their Patient Health Information for the purpose of treatment, payment, healthcare operations, 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 to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • HISTORY OF PRESENT AND PAST ILLNESS

  • Is this due to*
  • Have you ever had the same or a similar condition*
  • Date of last physical examination:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you have a history or stroke or hypertension?*
  • Have you been treated for any health condition by a physician in the last year?*
  • Have you received previous chiropractic care or physical therapy?*
  • Do you have any allergies to any medications?*
  • Do you have any allergies of any kind?*
  • Do you have any Congenital Condition (From Birth)*
  • Women: Are you pregnant?

  • Functional Rating Index

  • How would you describe your symptoms? (please check all that apply)*

  • For neck, back or other musculoskeletal symptoms: Please select the number which most closely describes your condition right now.

  • Section 1 – Pain Intensity*
  • Section 2 - Sleeping*
  • Section 3 – Personal Care (Washing, Dressing, etc.)*
  • Section 4 – Traveling (Driving, etc.)*
  • Section 5 – Work*
  • Section 6 – Recreation*
  • Section 7 – Frequency of Pain*
  • Section 8 – Lifting*
  • Section 9 – Walking*
  • Section 10 – Standing*
  • Have you had or do you now have any of the following symptoms/conditions?*
    Rows

  • SOCIAL HISTORY

  • Please indicate beside each activity whether you engage in it:*
    Rows
  • Please review the below-listed diseases and conditions and indicate those that are current health problems of the family member. Leave blank those spaces that do not apply.*
    Rows

  • I certify the information provided is accurate to the best of my knowledge:

  • Informed Consent

  • I hereby request and consent to the performance of chiropractic adjustments, acupuncture and/or other chiropractic procedures, including various modes of physical therapy and diagnostic X-rays, on me (or on the patient named below, for whom I am legally responsible) by the doctor of chiropractic named below and/or other licensed doctors of chiropractic who now or in the future work at the clinic or office listed below or any other office or clinic.

    I have had an opportunity to discuss with the doctor of chiropractic named below and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and other procedures. I understand that results are not guaranteed.

    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, strokes, dislocations and sprains. 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 or her, is in my best interest.

    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) f)or which I seek treatment.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: